Employees Election To Reject Coverage And Election To Waive Rejection Of Coverage For Excluded Persons {D-43}

Employees Election to Reject Coverage; and Election to Waive the Rejection of Coverage for Excluded Persons Pursuant to NRS 616B.656 Employee Name: Social Security #: Employer Name: Employer Address: NOTICE OF ELECTION TO REJECT COVERAGE Employee Signature: Date: NOTICE OF ELECTION TO WAIV E THE REJECTION OF COVERAGE Employee Signature: Date: Refer to Election of Coverage by Employer Form FOR WCS USE ONLY Method of Transmission First Class Mail [ ] Electronic Transmission/Fax [ ] Personally Served [ ] Date Notice Received: D-43 (Rev. 02/04)