Insurance SSL Declination Form

INSURANCE SSL DECLINATION FORM

Applicant / Insured Information

Policy Details

Policy Number:

Policy period: From to .

Coverage Being Declined

I hereby decline enrollment in the following coverage(s) offered under the policy identified above. I understand that declination applies only to the specific coverage(s) checked and does not necessarily terminate other coverages I may have under the policy.

Acknowledgement of Consequences

I acknowledge that by declining the selected coverage(s) I forfeit the protections and benefits those coverages provide. I understand that rejection of enrollment may result in reduced or no benefits payable for events that would otherwise be covered, and that reinstatement or future enrollment may be subject to evidence of insurability, waiting periods, or different premium rates.

I further acknowledge that any statements or representations made in connection with this declination may be relied upon by the insurer, plan administrator, or employer in determining eligibility for future coverage and benefits. I understand that any applicable premium deductions will cease for the declined coverages as of the effective date of this declination.

Exclusions and Limitations

The declined coverages may include exclusions such as losses attributable to suicide within applicable contestability periods, pre-existing condition limitations, and exclusions for losses resulting from war, illegal acts, or participation in hazardous activities. This declination does not alter exclusions or limitations that apply to other coverages I maintain under the same policy.

Beneficiary Designation (Optional)

Complete this section only if you wish to designate or confirm beneficiary information for any existing life coverage not being declined. If you do not complete this section, beneficiary designations on record remain in effect.

Declaration and Certification

By signing below I certify under penalty of perjury that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I acknowledge that I have been offered the coverage identified above and that I elect to decline such coverage voluntarily. I understand that if I later elect to enroll in the declined coverage, I may be required to submit satisfactory evidence of insurability and that coverage may not become effective until such evidence is approved and any applicable waiting periods have been satisfied.

I authorize my employer, plan administrator, or insurer to rely on this declination as a record of my election. I understand that falsification of information on this form may subject me to disciplinary action or denial of benefits.

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