I, the undersigned certify that I am waiving all medical, dental, and vision coverage offered by my employer, Bond Manufacturing. I understand that by not enrolling at this time, unless certain situations apply, I will be unable to enroll until open enrollment in December 2019.

 

Bond Waivers


 

Include Spouse/Domestic Partner and any other dependents

I acknowledge that the available coverages have been explained to me by my employer and I know that I have every right to apply for coverage. I have been given the chance to apply for this coverage and I have decided not to enroll myself and/or my dependent(s), if any. I have made this decision voluntarily, and no one, including but not limited to my employer, agent or life carrier, has tried to influence me or put any pressure on me to waive coverage.

BY WAIVING THIS GROUP MEDICAL, DENTAL, VISION, DISABILITY AND/OR LIFE COVERAGE (UNLESS EMPLOYEE AND/OR DEPENDENTS HAVE GROUP MEDICAL, DENTAL, VISION, DISABILITY AND/OR LIFE COVERAGE ELSEWHERE) I ACKNOWLEDGE THAT MY DEPENDENTS AND I MAY HAVE TO WAIT UNTIL THE NEXT OPEN ENROLLMENT TO BE ENROLLED IN THIS GROUP’S MEDICAL, DENTAL, or VISION, INSURANCE PLAN UNLESS I QUALIFY FOR A SPECIAL OPEN ENROLLMENT.

I also understand that if I wish to apply for Life coverage in the future, I may be required to provide evidence of insurability at my expense. Please note Spouse/Domestic Partner and Dependent coverage will not be available if the Employee has waived/declined.