Letter of Authorization to Participate in Medical Plan



Letter of Authorization to Participate in Medical Plan :




This letter should be typed in the official letter-head of the company.

The Company's Name

Door Number and Street's Name,
Area Name,
City.
Postal Code : XXXXXX
Phone Number : 0000 - 123456789


TO :

The Receiver's Name,
Door Number and Street's Name,
Area Name,
City.
Postal Code : XXXXXXX


Date :


Reference :


Dear _____________,


As an employee of [name of firm] , I do (do not) wish to participate in the Company's Medical Plan.


[name of firm] 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:___________________________


Yours Sincerely,


(The Sender's Signature)


The Sender's Name


Enc. :







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Letter of Authorization to Participate in Medical Plan
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