Form - Benefits Acknowledgement and Declination VA

Benefits Acknowledgement and Declination

Benefits Offer Acknowledgement VA

Date

Employee Name: *

Authorization

I acknowledge that I have been offered health coverage by my employer Grace Home Healthcare, LLC for the benefit period ending on September 30, 2022.  I have been given a summary of the health benefits offered and the employee contribution amount required to receive health coverage. 
                                                                                                                                       
I also understand that my election (to waive or enroll in health coverage) is irrevocable (cannot be reversed) for the benefit period ending on September 30, 2022, unless I experience an event (qualified life event) which allows me to make a midyear election change.

Signature *

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