AUTHORIZATION TO PARTICIPATE IN MEDICAL PLAN
As an employee of _________ [name of firm/Company] , I do /do not wish to participate in the Company’s Medical
Plan.
___________ [name of firm/Company] is hereby authorized to make the necessary deductions from my earnings
or any disability benefit paid to me by the company, for the amount specified in the Group Insurance Schedule.
It is my understanding that I will be eligible to participate in the Company Medical Plan as of ______ [date] and
that the monthly deductions referred to herein will begin on ________ [date]
I further understand that the acceptance of my application for participation in the Company Medical Plan is
contingent upon my ability to meet the medical requirements determined by __________
[name of insurance company]
Date:_________________
Signature:___________________________
