Employee Group Coverage Waiver Form

Who is this for?

Read these brochures to learn about our HMO group health care plans.

If your employees want to opt out of their Blue Cross coverage, have them fill out this form.

Your employees might have health benefits from somewhere other than work. Some might have coverage through a spouse or parent. Others might have an individual plan.

If they'd like to opt out of the Blue Cross Blue Shield of Michigan or Blue Care Network benefits you offer, have them fill out an Employee Waiver form (PDF). If you have Spanish-speaking employees, we also have an Employee Waiver form in Spanish (PDF).