Retiree Benefit Waiver Form

Retiree Benefit Waiver Form
This is to certify that I, First Name Last Name , have elected not to participate as a primary policyholder in the following WSSC Water benefit plans.

I understand that if I cancel my health, dental or vision plans, I will not be eligible to apply for these plans in the future.

Please fill in the plan name below that you wish to cancel:

      Health Insurance Plan
      Dental Insurance Plan       Plan Name
      Vision Insurance Plan       Plan Name
Retiree Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date
Signature
Please return the completed form to:
WSSC Human Resources Office, Benefits Division
14501 Sweitzer Lane, Laurel, MD 20707
or scan & email to HR_benefits@wsscwater.com
or fax: 301-206-8713
Should be Empty: