West virginia berkeley county 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name in the 'Print Name' field. This identifies you as the individual declining coverage.
3. Next, provide your signature in the designated area. This confirms your decision to decline the offered health coverage.
4. Fill in the date on which you are signing the form. This is important for record-keeping and compliance purposes.
5. Repeat steps 2 to 4 for the self-funded dental and vision plan section, ensuring all fields are completed accurately.

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