Name___________________________________
Effective Date______________________
WAIVER OF GROUP DENTAL INSURANCE
I have been given an opportunity to enroll in a group dental insurance plan offered by Occidental
College and provided by Delta Dental. I understand the benefits available and decline for the following
reason:
____ Coverage under my spouse’s plan
_____ Other
I understand that I may enroll in a College-sponsored dental insurance plan at a later date if I should lose
my existing coverage due to a family status change as defined by federal regulations. In addition, I may
enroll in a plan during the College’ annual open enrollment period.
Date________
Signature___________________________________________________