Fulton County Finance Form
WAIVER OF INSURANCE BENEFITS
EMPLOYEE NAME
SOCIAL SECURITY NUMBER
DEPARTMENT
WAIVING INSURANCE BENEFITS FOR:
SELF SPOUSE SELF AND SPOUSE
WAIVER OF BENEFITS FOR SELF
I, the undersigned, understand that I have been given an opportunity to apply for
Health, Dental and/or Vision benefits as offered by my employer and after careful
consideration, have decided to waive the following types of insurance coverage:
MEDICAL DENTAL VISION
I have attached proof of other coverage (insurance card). I understand that I will
not be eligible to participate in the health, dental and/or vision benefits program
offered by my employer from the effective date of this waiver until the next annual
enrollment period.
WAIVER OF BENEFITS FOR SPOUSE OF EMPLOYEE
SPOUSE’S NAME:
SPOUSE’S SOCIAL SECURITY NUMBER:
I understand that I have been given an opportunity to apply for Health, Dental
and/or Vision benefits as offered by my employer and after careful consideration,
have decided not to take advantage of this offer because my spouse, an
employee of Fulton County, has elected to provide my Health, Vision and Dental
Benefits as offered by Fulton County.
I understand that if my spouse discontinues this coverage that I will be required
to participate in the health, dental and/or Vision benefits as offered by my
employer from the date of discontinuance, and I agree to notify my employer if
my coverage has been discontinued so that my coverage will begin the date that
my spouse discontinues coverage.
EMPLOYEE SIGNATURE:
DATE:
