Benefits Declination Page

Please complete the benefits declination form below for the current plan year.

Benefits Offer Declination

Date

Employee Name: *

Authorization

I acknowledge that I have been offered health coverage by my employer HomeCentris for the current benefit period ending on September 30.  I have been given a summary of the health benefits offered and the employee contribution amount required to receive health coverage. 
                                                                                                                                       
After due consideration, I hereby decline the offer of coverage for the benefits year ended September 30.

Signature *

Clear

If you are human, leave this field blank.