Get Copower One Waiver Form

Filling out the CoPower ONE Waiver Form online is a straightforward process that ensures you correctly indicate your decision regarding enrollment in the CoPower ONE plan. This guide provides clear, step-by-step instructions to help you complete the form with ease.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the CoPower ONE Waiver Form and open it in your preferred editor.
2. Begin by providing your member information. Enter your full name and Social Security Number in the designated fields, followed by your employer's name and your CoPower ID#.
3. Indicate your reason for waiving enrollment in the CoPower ONE plan. If you are covered by another dental plan, fill in the ID/Group Number and the name of the carrier. If you do not have other dental coverage, select the option that states you decline to enroll.
4. Acknowledge your understanding of the waiver by confirming that you are waiving enrollment in dental, vision, and life coverages. Note that you may not be able to enroll later unless you show proof of loss of coverage under another dental plan.
5. Sign the form where indicated. Provide the date of your signature to confirm its authenticity. Ensure your employer also signs and dates the form to validate the declining coverage.
6. Once you have filled out the form completely, review all provided information for accuracy. You may then save any changes, and download, print, or share the form as needed.

Complete your CoPower ONE Waiver Form online today to ensure your decision is officially recorded.