ORANGE COUNTY
BENEFIT DECLINATION FORM
Name (please print) Date of Hire
Social Security Number Department Number
At this time, I do not wish to enroll for the benefit(s) designated. I understand that by declining
to enroll at this time:
1. I my subject myself and/or my eligible dependents to certain applicable waiting periods
if I decide to enroll at a later date.
2. I may be forfeiting the right to such coverage after my retirement.
I acknowledge that I understand that I am declining the noted benefit(s) at this time and that I
have received a copy of this document. I may, at a future date, enroll in the benefits I have
declined. I understand that there may be an additional waiting period between the times I sign
up for a benefit and the time it becomes effective.
I hereby decline to participate under any option of the Orange County HEALTH program
Signature Date signed
I hereby decline to participate under any option of the Orange County DENTAL program
Signature Date signed
I hereby decline to participate under any option of the Orange County VISION program
Signature Date signed
I hereby decline to participate under any option of the Orange County MEDICAL BUYOUT program
Signature Date signed
1/2016
