Being an employee not only gives an opportunity to an individual to receive a salary but also to receive other benefits which are inclusive in a company’s employment and workers’ compensation program. However, even if the benefits are automatically provided to an employee, it is still essential that the company will ask the employee’s approval and whether the employee needs the benefit or not.

Employee Waiver Form Sample

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What Is an Employee Waiver Form?

An employee waiver form is a document which should be filled out by an employee of a company who plans to relinquish or waive his rights and benefits towards a specific subject or item. After the employee completes the waiver form, he must immediately submit the form to the human resource personnel along with the required documents that will prove his claims with regards to the benefits and activities that he is waiving.

Employee Premium Conversion Waiver Form

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How to Create an Employee Waiver Form

Employee waiver forms vary on the subject which is to be waived by the employee, as well as the types of information which should be disclosed by the employee in order for the human resource personnel to process and document his waiver intent. To create a basic employee waiver form, the steps below must be followed:

Step 1: Add the logo and the name of the company. The company’s name and logo must be placed at the topmost portion of the form, either in the corner or in the center. Other information to add in this section would be the contact information and the address of the company, as well as the title of the form.

Step 2: Make an employee information section. The employee information section of the form should only collect the relevant or important details which will be used for the process of finalizing the waiver of the employee. Some of the basic information to be collected in this section would be the employee’s full legal name, age, gender, date of birth, as well as the employee’s job title, the date when he was hired in the company, and the company department where he is working in.

Step 3: Incorporate a waiver statement. The purpose of a waiver statement is to document the intent of the employee to waive for a specific subject. The details of what is being waived must be explained in this section of the form. For instance, if the employee is waiving the offer of a company to have his health insurance coverage be converted or be updated to a premium, the statement must not only indicate the employee’s refusal but also the details of the employee’s current coverage and the planned conversion.

Step 4: Include an affirmation statement. An affirmation statement is for documenting the employee’s affirmation and confirmation of the information that he disclosed in the waiver form to be true and are based only on facts.

Step 5: Allocate a signature block. This is the last section of the form wherein the employee will be able to affix his signature for both the waiver and the affirmation statements from the previous sections. Along with the areas for the employee’s signature must be a line for indicating the date when he used the form.

Moreover, an area for the human resource personnel can also be added into the employee waiver form below the last section to be completed by the employee. This is for stating the name of the staff who received and processed the waiver as well as the date when the waiver request was completed.

Employee Voluntary Waiver Form

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Examples of Employee Waiver Forms

There are different types and varieties of employee waiver forms that companies and organizations use, and these are enlisted below:

Employee Carryover Waiver Form – This variety of employee waiver form is intended to be provided to employees who have remaining funds from the previous plan year of the health care insurance that the company provided. For these employees, they must choose to whether or not carry over their funds from the previous year to the next plan year in order for them to be able to use the funds. However, there is also a disadvantage when carrying over the funds since it can affect the ability of the employee to have contributions in the next year which is why in the employee carry over waiver form, the details and explanations of about the funding and the contributions should be indicated.

Employee Carryover Waiver Form

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If the employee prefers to not use the funds and not permit the company to carry over his funds to the next year, he must complete and sign the employee carryover waiver form. In the form, the employee’s information will have to be disclosed such as his name, his social security number, his daytime phone number, and his electronic mailing address, as well as the name of his employer. Then, the employee should mark the checkbox which indicates his choice of electing to waive the carryover amount and affix his signature on the provided space in the form.

Employee Coverage Waiver Form – School employees who have their own or private health care insurance coverage, should waive the employee health benefits coverage that the school offers to them. This is to ensure that the employee will only be using one health coverage unless he will end his private insurance coverage. In the employee coverage waiver form, there will be two sections which are intended to be filled out by the employee and the employer or the school where the employee is employed. The first part or section of the form is for the employee wherein he will have to state his name, gender, date of birth, marital status, addresses, and employment status. Aside from the information of the employee, he must also indicate the purpose of why he is completing the form, whether he is waiving the coverage or simply reinstating the coverage. After which, the employee must affix his signature on the form.

Employee Coverage Waiver Form

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The second part of the form is to be filled out by the employer or the authorized representative of the school. This is where the employer will disclose the amount to be paid to the employee as part of the school’s assistance and financial aid for the employee who waived his benefits. On the other hand, an indication of the reinstatement should also be marked by the employer in the form to begin the process of the reinstatement.

Employee Dependent Tuition Waiver Form – Aside from the health benefits that educational institution employees can have as part of their employment package and workers’ compensation benefits, employees are also entitled to have discounts or yet a free tuition fee for their dependents who wants to study in the institution where they are working in. In order to inform the school about the need and the request of the employee in waiving the tuition payments of his dependents, the employee must complete an employee dependent tuition waiver form.

Employee Dependent Tuition Waiver Form

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An employee dependent tuition waiver form will collect the personal information of the employee and his dependents specifically their names, contact information, and their relationship to one another. The year when the dependent plans to attend or begin his studies in the institution will also have to be stated in the form along with the details of his course, ranging from the course title, course name, credit hours, and whether the course is to be taken online and with an audit.

Moreover, there is also a section in the form which requires the initial of the employee. This section is for informing the employee about the limitations and the responsibilities that he and his dependent must fulfill. Some of the included statements in this section focuses on the maximum audit which is eligible to be taken by the student per term, the inability of the student to take repeated courses, as well as the need for the student to abide in the rules and regulations of the institution throughout the period of his study wherein his tuition will be catered by the employee’s employer.

Employee Disability Waiver Form – If an insured employee or an insurance account holder gets into an accident and is severely injured, there is a possibility that the insurance company where he is enrolled in will not require him to pay the premium benefits due to his condition. If this happens, then the account holder should fill out an employee disability waiver form or a waiver of premium claim employee statement.

There are five sections in the form which are separated using letters and titles. The first section of the form is the identification section which is for identifying the employee who is signing the waiver form. In this section, the employee will basically state his personal data along with his insurance policy information, and his contact details. The second section of the form is the general information section which is intended for the details of the employee’s employment, the accident that he got involved in, and the actions that he took after the accident. It is essential that the employee will state the details of the accident such as the type of accident whether it is a work-related accident, a motor vehicle accident, or other types. The names and the contact numbers of the physicians who conducted medical exams and treatments to the employee must also be disclosed in this section.

Employee Disability Waiver Form

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The third section is the direct deposit enrollment information of the employee which should only be filled out if the employee prefers to have his benefit payments deposited directly to his personal account. The fourth and fifth sections, on the other hand, are for the rules, regulations, and the affirmations needed to be agreed by the employee in lieu of his waiver. This includes a personal information management statement which is important for informing the employee that his personal data will not be used for other intents aside from processing the waiver and the payments and a declaration and authorization to be signed by the employee in order for him to permit the company to use his disclosed information.

Employee Emergency Room Co-payment Waiver Request Form – Employees who have visited the emergency room of a medical institution and wants to have a medical reimbursement of the payment that they have given during their visit will have to use an employee emergency room co-payment waiver request form. This document will inform the State authority of audit and control about the request of the employee for the reimbursement.

In order to complete the form, the employee will have to state his name, employee identification number, his medical identification number, address, and contact information in the first section of the form. Additionally, if the employee is not the one who went to the emergency room but his dependent, then the employee will be required to state the general information of the dependent which should include the dependent’s name as the patient, the dependent’s medical ID, date of birth, and the dependent’s relationship with the employee.

Employee Emergency Room Copayment Waiver Request Form

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Other pieces of information to be disclosed in an employee emergency room co-payment waiver request form are the details of the treatment such as the name and address of the medical institution where the patient was brought, the date and time of the treatment, and the condition of the patient for which the emergency treatment was sought.

Employee Event Waiver Form – There are company events where the participation of employees are voluntary and not a requirement which means that the choice will be up to the employee if he will want to participate or not. If the employee chooses to participate in the company event, then he will be required to fill out an employee event waiver form.

Employee Event Waiver Form

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The employee event waiver form will be for documenting the approval of the employee to not hold the company liable for any unfortunate incidents where the employee will acquire an injury as he participates in the event. The information to be disclosed by the employee in the form includes the employee’s team name, address, and home phone number. To indicate the employee’s approval and affirmation of waiving the liability from the company, the employee must affix his signature below the waiver and release agreement statement along with the date when he signed the employee event waiver form.

Employee Medical Attention Waiver Form – Employees who have obtained injuries due to a work-related accident should submit an accident report to the management. And since it is a workplace accident, the company will be held liable to provide healthcare and treatment to the employees who were injured and severed, however, the company must also obtain the permission and the approval of the employee as well before any assistance will be given. In the event that an injured employee refuses to accept the medical assistance offered by the company for his injury treatments, the company must require him to complete an employee medical attention waiver form.

Employee Medical Attention Waiver Form

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The purpose of an employee medical attention waiver form is to document the refusal of the employee to have the treatments and the assistance of the company. In the form, the employee must disclose the contact information of his employer along with his own details. Then, he must state the date and time when the accident and injury were obtained as well as the injury type, the location or the specific area of the company where the employee had the injury, and the detailed description of how the injury was obtained during the accident. Lastly, the employee will have to sign the waiver authorization statement at the bottom of the form and submit the form to the human resource personnel of the company.

Employee Tuition Waiver Form – Not only the dependents of a school employee can obtain the educational benefits of the employee but also the employee himself. Basically, an employee tuition waiver form is a document to be used by an educational institution employee if he wants to pursue his study in the same school where he is working in. The form will be the instrument to inform the employer or the school about the employee’s request to waive his obligations in paying the tuition fees of the school in lieu of the course that he will be taking.

Employee Tuition Waiver Form

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There are three main sections in the form which must be filled out by the requesting employee and the authorized personnel of the school, but above the first section is a set of instructions and guidelines that the employee must note. The guidelines will allow the employee to know his eligibility for the educational benefits as well as his limitations and the enrollment or student application procedure.

The employee’s information and signature will be collected in the first section of the form while the details of his course and course credit will be disclosed in the second section of the form. In the third section, the authorized personnel will be the one who will complete the entry fields which are intended for indicating whether or not the employee has met the requirements and criteria for the benefits.

Student Employee Waiver Form – There are schools who offer student employment for their students who are in need, especially those who want scholarships yet have failed to meet the requirements and scholarship eligibility. For the working or employed students in an educational institution, a student employee waiver form must be used if there is a need to extend the working hours for the job and the required grade point average for a semester. Before the institution approves the working and service hours extension of the student as well as the changing of the grade point average which must be met every semester by the student for each subject and course, the student will need to undergo an assessment and verification process mandated by the administration.

Student Employee Waiver Form

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In a student employee waiver form, the student will be able to state what he is requesting along with his basic information, and the purpose or reason why he is needing the extension. If the administration of the institution declines, or yet gives conditional approval to the student, the reason for the declination and the actions to be taken by the student as a part of the agreed conditions need to be explained in the form. This is to inform the student and to allow him in deciding whether or not to continue with the extensions for his employment.

Additionally, the policies or rules and regulations which are required to be followed by the student employee are stated in a separate document sheet enclosed with the waiver to inform the student about any exemptions, terms, and the conditions of the institution regarding his employment and his role as a student.

Vendor Employee Waiver Form – Companies whose products and services are in line with the themes and the needs of music festivals, summer camp events, and other occasions are often required to submit a vendor employee waiver form from each of their staff who will be managing the company’s booth. In this variety of employee waiver form, the employee will be presented with paragraphs of agreements and considerations that he must keep in mind as he represents the company who is the vendor in the event. Some of the data to be stated by the employee includes the name of the company or the booth that he is managing, his and the company’s contact information, and the signature and names of the employee’s legal guardian if he is a working minor or student. Moreover, where the employee can mail or send his completed vendor employee waiver form is also incorporated in the form which is the business address of the event organizer.

Vendor Employee Waiver Form

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Even if there are tons of varieties to choose from, a company must ensure and inform their employees that the disclosed data and information in each variety of employee waiver form will be deemed confidential at all times unless the employee agrees for other parties to obtain his information. And yet, the agreement and the approval of the employee should be in a written document and not be done verbally only.

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