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Small Employer Health Benefits Waiver of Coverage Group Policy Number Policyholder Name Employee Name Last First MI Social Security Marital Status Single Married Widowed Divorced Date of Employment Date of Birth I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by CIGNA. I refused the following Employee Employee Spouse and Child ren coverage Spouse Coverage Child ren coverage Reason for Refusal Please check all appropriate boxes. Other group coverage sponsored by my employer Other reasons please explain Please provide name of carrier and policy number I understand that if I later wish to enroll for any of the coverage s refused I will be required to submit an Enrollment Form Signature of Employee Date Cigna is a registered service mark and the Tree of Life logo is a service mark of Cigna Intellectual Property Inc. licensed for use by Cigna Corporation and its operating subsidiaries. Small Employer Health Benefits Waiver of Coverage Group Policy Number Policyholder Name Employee Name Last First MI Social Security Marital Status Single Married Widowed Divorced Date of Employment Date of Birth I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by CIGNA. I refused the following Employee Employee Spouse and Child ren coverage Spouse Coverage Child ren coverage Reason for Refusal Please check all appropriate boxes. Other group coverage sponsored by my employer Other reasons please explain Please provide name of carrier and policy number I understand that if I later wish to enroll for any of the coverage s refused I will be required to submit an Enrollment Form Signature of Employee Date Cigna is a registered service mark and the Tree of Life logo is a service mark of Cigna Intellectual Property Inc* licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not Company Cigna Health Management Inc* Cigna Behavioral Health Inc* and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health Inc*. Small Employer Health Benefits Waiver of Coverage Group Policy Number Policyholder Name Employee Name Last First MI Social Security Marital Status Single Married Widowed Divorced Date of Employment Date of Birth I was given the opportunity to enroll in this plan of group health benefits offered by my employer and insured by CIGNA. I refused the following Employee Employee Spouse and Child ren coverage Spouse Coverage Child ren coverage Reason for Refusal Please check all appropriate boxes. I refused the following Employee Employee Spouse and Child ren coverage Spouse Coverage Child ren coverage Reason for Refusal Please check all appropriate boxes. Other group coverage sponsored by my employer Other reasons please explain Please provide name of carrier and policy number I understand that if I later wish to enroll for any of the coverage s refused I will be required to submit an Enrollment Form Signature of Employee Date Cigna is a registered service mark and the Tree of Life logo is a service mark of Cigna Intellectual Property Inc* licensed for use by Cigna Corporation and its operating subsidiaries.

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