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USA
Benefits:
You must enter effective date
Coordination of Benefits / Other Coverages:
If yes to above, please give Employers / Insurers Name, Address and Effective
Date of Coverage:
Family Coverage Dependant Information:
Life Insurance:
Benefits and Terms Acceptance:
Not Signed! Will not process!
Employee Signature
I hereby request that amount(2) and Forms of Coverage for which I am or may
become eligible and hereby authorize my employer to deduct the required
contributions, if any, from my earnings. If you decide not to apply for Coverage
at this time, sign the declination below.
Benefits and Terms Declination:
Employee Signature
If you are declining enrollment for yourself or your dependents (including
spouse) because of other health insurance coverage,you may in the future be able
to enroll yourself or your dependents in this plan, provided that you request
enrollment within 30 days after your other coverage ends. In addition, if you
have a new dependent as a result of marriage, birth, adoption or placement for
adoption, you may be able to enroll yourself and your dependents, provided that
you request enrollment within 30 days after the marriage, birth, adoption or
placement for adoption.
Note: Any person who knowingly presents false or fraudulent claim for payment of
a loss or benefit or knowingly presents false information in an application for
insurance, is guilty of a crime and may be subject to fines and confinement in
prison.