Declination Of Coverage - Sackett & Associates Insurance
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1Small Business
DECLINATION OF COVERAGE
Employee name (please print):
INSTRUCTIONS
Please use this form to decline coverage, not to terminate a subscriber or member. If you would like to terminate a subscriber or member, please
use the Subscriber Termination/Transfer form.
Employers: Keep a copy of this form for your records.
COMPANY INFORMATION
Company name
Customer ID (if assigned)
Street address (no P.O. boxes)
City
State
ZIP
Office phone
Ext.
Fax
(
)
–
(
)
–
REASON FOR DECLINING
I have been offered Kaiser Permanente group health coverage by my employer. I voluntarily choose not to enroll myself and my dependents in a Kaiser
Permanente plan at this time. I understand that the next opportunity to enroll will be during the annual open enrollment period.
Reason for declining (check one):
I am covered by another employer’s health plan through my spouse/domestic partner/parent.
Name of carrier:
I am covered by another plan offered by my employer.
Name of carrier:
I am covered by an individual health plan.
Name of carrier:
I am covered by Medicare, Medi-Cal, or Tricare.
Other reason for declining:
SIGNATURE
Employee name (please print)
Social Security number (last 4 digits)
Signature
Date
X
You may be eligible to enroll yourself and your dependents before the next open enrollment period if a qualifying event, such as losing other coverage,
occurs. If your situation changes, please contact your employer immediately for more information.
Small Business
60135409 October 2013
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Parent category: Business