Insurance & Risk
Insurance Coverage Waiver/Declination
Formal declination of insurance coverage with acknowledgment of risks. Single signer (individual).
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# Insurance Coverage Waiver/Declination **Date:** ___________ This Insurance Coverage Waiver/Declination ("Waiver") is executed by: **Individual:** ___________ ("Individual") In connection with coverage offered by ___________ ("Offering Entity"). ## 1. Coverage Offered and Declined The Offering Entity has made the following insurance coverage available to the Individual: **Type of Coverage Offered:** ___________ **Insurance Carrier/Provider:** ___________ **Plan Name/Level:** ___________ **Coverage Period:** ___________ to ___________ **Premium Amount:** $___________ per ___________ **Employer/Entity Contribution (if any):** $___________ ## 2. Reason for Declination The Individual declines the above coverage for the following reason: ___________ **Additional Details (if applicable):** ___________ **If covered elsewhere, provide:** **Alternative Carrier Name:** ___________ **Alternative Policy/Group Number:** ___________
Fields (18)
effective date
date · required
individual name
text · required
offering entity
text · required
coverage type
select · required
insurance carrier
text · required
plan name
text · required
coverage start
date · required
coverage end
date · required
premium amount
text · required
premium period
select · required
employer contribution
text
declination reason
select · required
declination details
textarea
alt carrier
text
alt policy number
text
affected dependents
textarea
governing state
select · required
individual signer name
text · required
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