Get Declination Of Coverage Template

Filling out the Declination Of Coverage Template online is a straightforward process that allows you to formally decline medical coverage offered by your employer. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to fill out the Declination Of Coverage Template online

1. Press the ‘Get Form’ button to access the Declination Of Coverage Template and open it for editing.
2. Enter your last name in the designated field under the *Employee section. This is a required field.
3. Fill in your first name and middle initial in the corresponding fields, ensuring all information is entered correctly.
4. Provide your complete address, including city, state, and zip code in the required sections.
5. Input the group or employer name in the specified area. This identifies the employer providing the coverage.
6. Indicate your occupation in the relevant field. This information helps classify your position.
7. Enter your hire date in the designated section to clarify when you began employment.
8. Input the effective date of coverage in the required area, which tells when your coverage would have started if accepted.
9. If applicable, provide the COBRA effective date or state continuation information to signify any federal or state continuation of coverage.
10. Fill in your employer sub-group number if required by your employer’s health plan.
11. Clearly state whether you are waiving medical coverage for yourself and any eligible dependents in the options given.
12. Specify the reason for waiving coverage. Choose from the options or explain other reasons briefly if necessary.
13. Provide your home and work phone numbers, as well as an email address, so your employer can contact you if needed.
14. Submit the form after reviewing all entries for accuracy. You may have options to save changes, download, print, or share the completed form as needed.

Start filling out your Declination Of Coverage Template online today.