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Asia-Based Personnel Employee Declination of ELIC Provided Medical Evacuation Insurance Employees and their families have the option of declining ELIC provided medical evacuation insurance. 1. The employee must provide proof of alternate medical evacuation insurance. A copy of your insurance card must be attached to this form. 2. The employee must complete and sign this waiver. 3. If ELIC provided medical evacuation insurance is declined, your next opportunity to enroll would be in August 1. If you or a family member were to lose your current evacuation insurance, you could be eligible for enrollment. Check with Becky Henderson for details. My policy is held with: Name of insurance carrier:__________________________________________________________________ Group # or Plan # (if applicable): __________________________________________________________ Address/City/State/Zip: ____________________________________________________________________ Telephone #: _________________________________________________________________________________ I have been given opportunity to apply for medical evacuation insurance as offered by my employer, and after careful consideration, I have decided not to take advantage of this offer for myself and my family (if applicable). I understand that in the event I should decide to apply for such coverage hereafter that such subsequent application shall be subject to the applicable terms and conditions which may require waiting until open enrollment in August. By signing this document, I have read and completed this document, attached my insurance information, and am declining ELIC provided medical evacuation insurance. Employee Name:__________________________________________________ Please Print Employee Signature: _____________________________________________


For office use only Effective Date:______________________ Received by Global Support Services:__________________________________________ Date:______________________________ If you have any questions about completing this form, contact Becky Henderson at 970-530-3819, or email her at Rev. 8/2012

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