DECLINATION OF INSURANCE

    I, _______________________________________, hereby decline the [ ] Dental Insurance, and/or
   [ ] Health Insurance program for myself and my eligible dependents (if any), offered by my employer.
    I understand if, at a later date, I request insurance which I have DECLINED above, I will subject
    myself to applicable waiting periods, set-up charges, and may be required to furnish evidence of
    insurability to, and at no cost to the insurance company or my employer.

______________________________ __________________________________
Employee Name (Please Print) Social Security Number

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Employee Signature Date

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*	EMPLOYER USE ONLY		*
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*	Employer Name		*
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*	Authorized Signature	Date	*
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