Waiver of Group Insurance

Graphic Arts Benefit Corporation
6411 Ivy Lane, Suite 700
Greenbelt, MD 20770-1411

Employer

Employee Name

Date of Hire (MM/DD/YY)
 

Today's Date (MM/DD/YY)
 

I hereby certify that I have been given an opportunity to enroll for group insurance benefits offered by my employer.
These benefits would be effective on (MM/DD/YY)   However, I decline to enroll at this time for the reason specified.

Reason for waiver of enrollment:

I do not wish coverage at this time

I am currently covered under another insurance arrangement

If covered under another insurance arrangement the following information must be supplied:
 

Policy/Certificate Holder's Name

Insurance Company Name

Insurance Company Address

Insurance Company Telephone Number

Group Policy & Certificate Number

Effective Date of Coverage (MM/DD/YY)
 

Type of Coverage (Medical/Dental/Vision)

Signature of employer representative

_________________________________________________(please submit this form, print, sign and mail a copy to GABC)

Signature of employee

_________________________________________________(please submit this form, print, sign and mail a copy to GABC)

________________________________

98EMPWAIV

Graphic Arts Benefit Corporation

Please Click on the SUBMIT BUTTON only ONCE. Your request will be processed.

Don’t forget to print this form sign & date it and mail to:

Graphic Arts Benefit Corporation
6411 Ivy Lane, Suite 700
Greenbelt, MD 20770-1411