[l-Date]
To:
[r-Name]
[r-Address]
From:
[s-Name]
[s-Firm]
[s-Address]
[s-Phone]
RE: [s-Reference]
Dear [r-FName]:
As an employee of [s-Firm], I do
(do not) wish to participate in the Company’s Medical Plan.
[s-Firm] is hereby authorized to (not)
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 [s-PlanDate] and
that the monthly deductions referred to herein will begin on [s-BegDate].
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 [s-InsurCompName].
Thank you for your assistance in
this matter.
Best regards,
[s-Company]
[s-Name]
[s-Title]
