Employee's Election to Reject Coverage; and Election to Waive the Rejection of Coverage for Excluded Persons
Pursuant to NRS 616B.656
Employee Name: Social Security #: Employer Name: Employer Address:
NOTICE OF ELECTION TO REJECT COVERAGE Employee Signature: Date:
NOTICE OF ELECTION TO WAIVE THE REJECTION OF COVERAGE Employee Signature: Date: Refer to Election of Coverage by Employer Form
FOR WCS USE ONLY Method of Transmission Electronic Transmission/Fax [
First Class Mail [ Date Notice Received:
]
]
Personally Served [ ]
D-43 (Rev. 02/04)