Arabic Benefits Waiver Form

Benefits Waiver Form
Form Name
Name*

First NameLast Name
Mailing address*

Street Address

Street Address Line 2

CityState

Zip Code
Is your home address the same as your mailing address?*

YesNo
Home address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Social Security NumberDeprecated*
Social Security Number*
Preferred Language
Provider number
Preferred Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
*

Cell phoneLandline
Check this box to receive important updates from RISE Partnership about Carewell SEIU 503 benefits by text. You may receive up to three messages per month. Standard message and data rates may apply. Reply STOP to end.
Email Address
example@example.com
I acknowledge that I have been offered Carewell SEIU 503 Dental, Vision+Hearing, and Employee Assistance Program (EAP) coverage through the Oregon Homecare Workers Benefit Trust. By my signature below, I am declining this coverage because:*

I have coverage through my spouse, partner, or parent’s employer.I have coverage through another employer.Other (specify reason):
By signing below, I understand that I am voluntarily waiving my right to coverage for which I am otherwise eligible through the Oregon Homecare Workers Benefit Trust.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: