This is to certify that I have been given the opportunity to apply for group dental insurance available to me through my employer and I have decided that I do not want to enroll

First Name

Last Name

Street Address

City

State

Zip Code

Date of Birth

Please place initials in box. By entering my initials in this box I certify that I understand that I have been given the opportunity to enroll in the Delta Dental program and am declining to enroll at this time. I understand that I may not change this election except upon a qualified life event or during open enrollment.

Please type your Full Name in the box below. By typing my name in this box, I acknowledge that I am using a typed signature in place of a written signature and that the information in this waiver pertains to me and is truthful and accurate to the best of my knowledge.