Free D-43 - Nevada

Employee's 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 WAIVE THE REJECTION OF COVERAGE Employee Signature: Date: Refer to Election of Coverage by Employer Form

FOR WCS USE ONLY Method of Transmission Electronic Transmission/Fax [

First Class Mail [ Date Notice Received:

]

]

Personally Served [ ]

D-43 (Rev. 02/04)