Insurance Coverage Waiver/Declination

# 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:** ___________