Pandya Network

New Hire Checklist

Employee: ________________________

Location Name: ________________________

Location Address: ________________________

Hire Date: ________________________

_______Employment Application
_______Photocopy of Social Security Card
_______Photocopy of State I.D./Driver’s License
_______Completed I-9
_______Completed W-4
_______Review Employee Handbook
_______Employee Handbook Signature Page
_______New Hire Agreement (Give a copy to the signor)
_______Complete the Basic Orientation Checklist & Walk Thru
_______Create (or transfer) DB Online University User ID/Password
_______Signature for Hazardous Communication Training Program (HAZCOM)
_______Signature for Bodily Fluids Kit Training Program
_______Enter Employee into Radiant Management System
_______POS Pin # ______________________
_______Health Care Waiver Acknowledgement
_______FULL Timers – after 90 days only: Health Care Enrollment Option
_______E-Fax completed packet to (773) 326-3687

1
 Dunkin Donuts / Baskin Robbins

Pandya Network
Employee Handbook

Version 1.18

2
Welcome to the Pandya Network. We are glad you have decided to join our network of Dunkin Donuts
Baskin Robbins. As a new member of our organization we will be working with you to develop your
skills in teamwork, customer service, professionalism, basic accounting, and management.

This handbook was designed to answer any questions you may have entering you new position, as well
as be a valuable resource to make sure you adhere to our policies. Please make sure you are comfortable
starting your new career at the Pandya Network and if you have any questions never hesitate to ask a
manager.

We are glad to have you a part of our restaurant team and once again welcome to the Pandya Network.

Ashok Pandya & the Management Team

America Runs on Dunkin and Dunkin Runs on You!

Disclaimer:
This revised January 19, 2018 Handbook was intended to provide general information and guidelines to
this restaurant’s procedures and policies. It is not intended and does not create a contractual agreement.
The restaurant owner reserves the right to modify, create or revoke any benefit or policy and procedure
listed within this handbook, in part or in whole, at anytime with or without notice. *This Handbook,
including any attachments, is for the sole use of the addressee(s) to whom it has been sent, and may
contain information that is confidential or legally protected. If you are not the intended recipient or have
received this message in error, you are not authorized to copy, distribute, or otherwise use this message
or its attachments. ALL INFORMATION IS CONFIDENTIAL! DO NOT SHARE ANY
INFORMATION WITHOUT THE WRITTEN PERMISSION OF ASHOK PANDYA AND THE
UPPER MANAGEMENT TEAM.

Employment at this restaurant is at will and may be terminated at any time with or without notice and
with or without cause.

3
Store Information

Main Franchisee: Ashok Pandya

Franchisee: Ravi Pandya
Franchisee: Chetan Jani
Multi - Unit Manager: Jamie Gomez
Multi - Unit Manager: Sapan Shah
Multi - Unit Manager: Guadalupe Calderon
Multi - Unit Manager: Riya Amin
Office Team: Kruti Pandya, Rajshree Pandya, Alex Bura

Restaurant Manager:

Restaurant Phone Number:

Restaurant Address:

Restaurant Store Number (PC #):

Store Hours of Operation:

The Pandya Network strongly feels that is important to address any issues or concerns you may have
about your current position. Please defer any questions / comments to your local store manager. If any
issues arise where your store manager can no longer fulfill his/her duty of assisting you, please contact
your designated Multi-Unit Manager.

4
Structure of Dunkin Brands

Dunkin Brands Inc. franchises Dunkin Donuts and Baskin Robins to independent owners (the
franchisee). Operated through a franchise agreement, Dunkin Brands provides ongoing support and
assistance to the development of the restaurants. You will have a chance to meet Dunkin Brands
Representatives including the Operations Manager (OM). You manager will provide you with more
information regarding Dunkin Representatives.

Training

There will be several resources available to you when you begin your position at the restaurant. Please
do not hesitate (at any time) to ask your Manager or Shift Leader(s) questions you may have. Prior to
start of employment, you will be assigned your own User ID and Password to access online courses
provided by Dunkin Brands. Please be aware that it is mandatory that all employees finish online
training within 30 days of employment, to ensure that you are capable of providing 100% customer
satisfaction. In the State of Illinois it is mandatory that all employees complete Food Handler Training
and obtain a Food Handlers Certificate within 30 days of hire. If a new hire already has a ServSafe
certificate, they will not be required to obtain a Food Handlers Certificate also.

The DB Online University website is: [Link]

The Food Handlers Classes are available for $7.00 at: [Link]
*Computers will be available at your restaurant, may vary by location

Performance Standards

In order to maintain a professional and courteous image, certain performance standards must be upheld.

Job Performance

 Give prompt, courteous, and friendly service to all guests.

 Never argue with a guest.
 Do not chew gum, eat, smoke, or drink in unapproved areas of the restaurant.
 Show up on time in a clean uniform prior to each shift.
 Make necessary arrangements for time off.
 Be considerate to all crew members by not leaving a mess and making sure that all
tasks/assignments are completed by the end of your shift.
 Follow instructions and be adaptable to change.
 Work independently when unsupervised.
 You may not swear or make obscene gestures.
 Friends & Family are welcome at the restaurant as guests, but they may not interfere with your
responsibilities or duties.
 Alcohol or illegal substances are not permitted on the restaurant premises. Do not report to work
under the influence of alcohol or illegal substances.
 Handing out any free product will be considered theft and will constitute the same terms as theft

5
Salary

The current salary allotted per restaurant may vary. Your hourly pay will be determined at the time of
hire. Job performance and prior experience will play a role in determining how your hourly rate will be
calculated.

Checks will be dispersed by the manager bi-weekly, with pay day being on Mondays. By signing this
Network Handbook, you are hereby acknowledging and agreeing to the terms of the Payroll and Pay
Day system we have in place. If you are unable to pick up your check, please make arrangements with
the manager to obtain it. With each check, on every pay period, the Pandya Network will provide you
with a pay stub, which includes the gross pay with the deductions itemized and a net amount. If you are
to lose a check, the issuing bank will charge for stop payment on the check, which the employee will
incur as a deducted expense on their check.

Policies

Several policies have been outlined to provide a better understanding of what is expected from you. If
you need clarification or would like more information on any certain policy, do not hesitate to ask your
store manager.

Dress Code Policy

Prior to punching in to your shift you are required to be in full uniform with all articles present. You
may wear shoes which are more comfortable to you, but it is required that they are to be close toed and
may not be high heels. Note items #1-3 are provided by the restaurant and the approximate cost will be
deducted from the first paycheck as a Uniform Deduction and the items are yours to keep.

The items that must be worn are:

1. Uniform Hat or Visor (provided by your restaurant).
2. Uniform Apron (provided by your restaurant).
3. Name Tag (provided by your restaurant).
4. White Collared or Turtleneck Shirt.
5. Appropriate Blue Jeans Slacks / Pants.
6. Closed-toed shoes.
7. Socks.

The only jewelry that is allowed is a plain ring, non-dangling earrings (in the earlobe only), or a plain
necklace, which would be worn inside the uniform. No hand jewelry is permitted for guest safety.

Smoking Policy

To comply with governmental regulations, it is prohibited to smoke throughout your workplace. The
restaurant has a smoke free environment; smoking is not permitted inside the restaurant. Furthermore,
as long as you are on restaurant property (inside or outside) you may not smoke within 30 feet of the
location or any time that you are in the store’s uniform. Any violation of this policy may result in
disciplinary action, up to and including termination of employment.

6
Shift Schedules

You will be notified in advance if there is a change in your schedule. The restaurant manager or
authorized Shift Leader may at times make same-day shift changes as per business needs without prior
notice. Please take time to review your schedule and make certain to know where your restaurant posts
your schedule. You are expected to be on time and work all your scheduled shifts. You will be given a
trial period for 30 days to see if you are a good fit for the location, and thereafter the manager will
decide the schedule. If you are unable to come for an emergency, you will notify the manager 24 hours
in advance. If you call-off work due to medical reasons, then please bring the doctor’s note. If you need
to request a day off, then you will notify the manager 1 week in advance.

Prior to clocking in and out, you should be in full uniform. Please remember you are a part of a team
and if for any reason you are unable to work your scheduled shift you are required to contact your
Manager/Shift Leader prior to the start of your shift. Only you may clock yourself in and out. If any
other employee is found to be punching you in or out that is grounds for immediate termination for the
person being clocked and for the person doing the action of clocking in or out. If you have any
questions pertaining to your shifts please contact your manager immediately.

Telephone Policy

You may not use a cellular phone (to talk, text, email, or for social media of any kind) at anytime you
are working, unless it is an emergency related to the restaurant or you have prior approval from a
manager. Store phones are not to be used for personal calls. Please know the location of all emergency
numbers. If there is excessive phone use, then please note your manager may write-up the concern.

Register Policy

During your shift, you are responsible for your register. Please make sure to count your register prior to
ringing up sales and at the end of your shift on the register. No one may touch a register that was not
assigned to him/her. At the end of your shift, money overages/shortages should not exceed +/- $1.00.

Personal Grooming

Every employee must meet certain standards of personal grooming when working any foodservice
career. These standards not only create an impression for our restaurant and customers, but also ensure
the proper and safe handling of the products we sell and serve. Please be aware of the standards that we
require.

 Skin, hands, and teeth must be clean.

 Hair must be clean, neatly combed, short (not touching the collar) and/or restrained.
 Mustaches and beard, if allowed by local health codes, must be short and neatly trimmed.
 Excessive make-up, any type of lotion, and heavy perfume are not permitted.
 Nail polish and acrylic nails are not allowed. Nails should be short and clean.

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Online And Social Media Policy

Even though personal web pages on social media sites such as Snapchat, YouTube, Facebook, Twitter and others
are great forums for self-expression and communicating with your friends, you still must follow proper guidelines
and policies.

If you talk about the Dunkin Donuts or Baskin Robbins brand online (e.g., blogs, message boards, forums, videos,
photos, etc.), please make sure you are respectful. Everything you post can be tracked, and anything that
breaks the law and/or Pandya Network policies could result in disciplinary action. Remember, even if you
delete a picture or a post, it still may end up available online forever.

Cameras of any type are not allowed in our restaurants without written approval from the store owner.

Cell phones are also not allowed in the food prep/food service area.

Here are rules/policies for online and social media:

 Always be respectful about Dunkin Donuts restaurants, their employees, your co-workers & customers.
You can talk about your job, but keep comments positive and don’t use names.
 Be respectful of the Dunkin brand even when you are off the clock. Don’t let the things you do
and say reflect poorly on you, your job or your community.
 Never post inappropriate videos or photos, especially of anything that happens in the restaurant.
 Don’t post any Dunkin restaurant operational guidelines online, including reference guides, training
materials or Job Aid materials. This information is confidential and proprietary.
 When you express your comments make it clear that what you’re saying is your opinion.
 If you post an endorsement about the Dunkin brand you should make it clear that you are a restaurant
employee. Think about the consequences of your actions. Dunkin Brands monitors online postings and
notifies franchisees of postings concerning their restaurant(s). Be aware that all crimes including theft,
vandalism and health code violations will be reported to the proper authorities.

Additionally, if someone is videotaping at the restaurant, either in the drive-thru or lobby, please contact
the Restaurant Manager directly as well as any present Shift Leader.

I understand that it is my responsibility to comply with this policy. Failure to do so may lead to
termination and/or other legal consequences. I have received and read a copy of the Online and Social
Media Policy on the date listed below. I understand that this form will be retained in my personnel file.

SIGNATURE OF EMPLOYEE WILL BE ON LAST PAGE OF HANDBOOK

8
Staff Food Policy

Any meal brought into work must be stored in a designated area. You must eat all meals in a designated
break area. You are to clean your area prior to returning to work and store all leftovers / containers in
the designated area.

This restaurant has a vast variety of meals, treats, and goodies. Each store’s policy varies for what staff
food is included during scheduled work hours. You may purchase any products, which are sold at a
_____% discount, but it may only be eaten during your designated break, in the designated break area
away from customer view. The employee discount is complimentary for only you, as an appreciated
employee, and does NOT apply to outside friends and family.

Breaks

You must remain in the store for non-clocked out breaks, but may leave if you are clocked out. Please
make sure you return to your shift on time. Illinois law requires employers to permit employees who are
to work 7½ continuous hours or more to take a meal period of at least 20 minutes. The meal period may
be unpaid and it must be given to an employee no later than 5 hours after beginning work. You are not to
disturb any on-the-clock employees while on break.

Food Safety Certification Policy

Depending on the location of your restaurant, either of the following will be required:
 CHICAGO FOODSERVICE MANAGER
 SERVSAFE CERTIFICATION
 AND FOOD HANDLERS CERTIFICATES

By signing this Handbook, I agree that I will be receiving a Sanitation Certification with my employer under the
conditions set forth below:

For the ANSI Food Handler Course, that is required for all food service employees in the State of IL, I will
complete the certification through the following website: [Link] I will be
responsible for the full $7.00 course fee since the certificate is valid for 3 years and will be my property even if I
leave my employment. Email is required for this online course certification.

For the Servsafe or City of Chicago Certified Foodservice Manager Certificate, at the time of the course
certification, my employer will be paying for the course fees that are listed below. However, course fees being
paid by my employer are subjective to my employment continuation.
o If I continue employment with the same employer for a year after receiving the mailed copy of my
certificate, then my employer will pay the full cost.
o If I discontinue employment with the same employer within a year after receiving the mailed copy of my
certificate, then I will be liable for paying my employer the full costs before receiving my final check.
o Scan final copy to pandyanetwork@[Link] or Fax to 1-773-326-3687.

9
Safety & Security

Your safety and security is important to us! Many areas of concern will be covered on the Online
Training Course. The Store Safety & Security Online course is mandatory for all employees. Under no
circumstances is a non-employee of your store allowed behind the dining area in the restaurant. Keep all
back doors locked at all times. If you must open the back door (for deliveries or throwing trash) have
one person posted at the back door.

Due to this employment being a food-oriented position, it is extremely important to notify a manager
immediately if you have an illness or sickness. Work-related injuries need to be notified to a manager
immediately. If you are concerned with any safety or security issues notify a manager immediately.

Healthcare

If you are working full-time on a weekly basis, then your employer will be offering you the healthcare
option through the company's provider. The employee contribution will be no more than 9.5% of your
earned wages. If you select to not purchase health insurance through your employer, then you must sign
a waiver that states you are declining coverage. Contact your restaurant's store manager with any further
questions.

We are an Equal Opportunity Employer

We will maintain a policy of nondiscrimination with all employees and applicants for employment. All
aspects of employment with us will be governed on the basis of merit, competence, and qualifications
and will not be influenced in any manner by race, color, religion, sex, age, marital status, national origin,
handicap, or veteran status.
All decisions made with respect to recruiting, hiring and promotions will be based solely on individual
qualifications related to the requirements of the position. Likewise, all other personal matters such as
compensation, benefits, transfers, and social/recreation programs will be administered free from any
discrimination.

If any employee encounters any abuses from any supervisor or fellow employee, it is the duty of that
employee to report the act to a member of management within 48 hours. Management will thoroughly
investigate all complaints in a confidential manner and any complain that is found to be valid will have
immediate appropriate disciplinary action taken.

Given the nature of the type of discrimination, we recognize that false accusations of sexual harassment
can have serious effects on innocent women or men. We trust that all employees will continue to act
responsibly in order to establish a pleasant working environment free of discrimination.

Resignation

Prior to resignation, it is in the employees’ best interest to talk to a manager to see if they can work an
alternative out to the issue or concern at hand.

10
Every employee is “at-will” to leave the Pandya Network. There are no contractual rights, written or
expressed, to remain an employee of the Network, unless the president of the company assigns it
himself. An employee may leave at anytime, with or without written/verbal notice. An employee may
also be terminated with or without written/verbal notice. It is strongly suggested that every employee
leaving the Network give a minimum of a two-weeks written notice prior to his or her leave.

When leaving the network you are required to return:

 Office Keys/ Swipe Cards/ Name Tags
 Company Manuals/ Company-Issued Credit Cards
 Any additional Company-Owned Property including Training Certificates

Termination without Notice

There may be termination without written notice in some instances. This list includes, but is not limited
to the following:

 Stealing restaurant or fellow employees’ property.

 Verbal or physical abuse of a customer or staff member.
 Working under the influence or selling alcohol or any other illegal substance on the premises.
 Failure to adhere to your work schedule without the permission of the Manager.
 Failure to make a shift deposit at the end of your shift.
 2 or more written write-ups.
 Giving unauthorized food/drink to any employee, customer, family or friend.
 Excessive phone use.
 Excessive misuse of company time.

[ SIGNATURE PAGE TO FOLLOW ]

11
 Pandya Network
Employee Handbook

By signing this form, I agree to abide by the policies set forth in this revised edition Version 1.18 of the
Pandya Network employee handbook. I also understand that policies or procedures may be modified,
created, or revoked at anytime. It is my responsibility to confirm that I am within the most current policies
and procedures.

I have thoroughly read and understood this employee handbook in its entirety. If there were any questions
within this handbook, I have already received an answer from my manager.

________________________________________/_____/____
Employee (Signature) Date

__________________________________
Employee (Print Name)

________________________________________/_____/____
Manager (Signature) Date

__________________________________
Manager (Print Name)

12
 DUNKIN DONUTS NEW HIRE AGREEMENT (GIVE COPY TO SIGNOR)
I agree to the following terms for my employment at the Dunkin Donuts: ______________________________

1. Show up on-time work as scheduled. The manager puts up the schedule every week, so it is my responsibility
to call the # ____________________ for my schedule. I will be given a trial period for 30 days to see if I am a
good fit for this location, and thereafter the manager will decide my schedule. If I am unable to come for an
emergency, I will notify the manager 24 hours in advance. If I need to request a day off, then I will notify the
manager 1 week in advance.

2. Training- I understand I will need to fully complete my online training according to Dunkin Donuts. Please be
aware that it is mandatory that all employees finish online training, to ensure that you are capable of providing
100% customer satisfaction.

The training website is: [Link]

My online user ID will be: ______________________________________
My password will be: Pc______________

3. Work honestly- I understand that I will receive a ____discount on any food I purchase during non-scheduled
work hours. During working hours only, coffee/donuts are complimentary for myself ONLY, as an appreciated
employee. My employee discount does NOT apply to my friends and/or family.

4. Fast, Clean, & Guest-Oriented (FCG) Behavior - I understand the importance that customers always come
first. I promise that each customer will be greeted with a friendly smile and welcomed in a clean restaurant
within 3 seconds of entering Dunkin. I will ensure travel paths are conducted every 30 minutes. I will clean as I
go to ensure I successfully fulfill my work duties.

5. Work in proper uniform- I understand the importance of showing up on time for my scheduled hours in a
proper uniform including a white collared/turtleneck shirt, blue jeans, a brown apron, my nametag, &
visor/hat. It is my responsibility to order these with the owners & the purchase will be taken out from my first
paycheck. The total amount due is _____. These items will be mine to keep, shall I choose to after employment
has ended.

If I am found in default of any of the above-mentioned, but not limited to, terms, then I will be terminated from my
employment immediately. Also, if I chose to voluntarily leave, then I will give a 2 week written notice to receive full
payment of my final paycheck.
________________________________ (Employee Name)
________________________________ (Employee Signature)
________________________________ (Primary Number)
________________________________ (Emergency Contact Name)
________________________________ (Emergency Contact Number)
________________________________ (Manager Name)
________________________________ (Manager Signature)
________________________________ (Date)
*This document, including any attachments, is for the sole use of the addressee(s) to whom it has been reviewed with, and may
contain information that is confidential or legally protected. If you are not the intended recipient or have received this message in
error, you are not authorized to copy, distribute, or otherwise use this message or its attachments. ALL INFORMATION IS
CONFIDENTIAL! DO NOT SHARE ANY INFORMATION WITHOUT THE WRITTEN PERMISSION OF THE PANDYA
NETWORK.

13
Basic Orientation Checklist Job Aids
Employee Name: ____________________ Turbochef
Trainer Name: ______________________ Sandwich Station
Completion Date: ____________________ Back Room / Donut Production
Bagel Oven
Store Walk Thru Checklist Muffin / Croissant / Cookie Oven
Dry Storage Area / Walk-in Cooler /
Employee Parking Walk-in Freezer
Work Schedule Training Station
Wage Policies Cash Registers
Uniform Requirements Designated Break Area
Restaurant Policies Cash Registers
Termination Polices Drive-Thru System
Emergency Number Dining Area
Introduction to Staff Washroom
Restaurant Tour Coolers
Menu Explanation Back Door / Dumpster Area
Product Identification Parking Lot / Sidewalks (if cleaning is
Travel Path (every 30 minutes) required)
Huddle board (GSS, goal setting) 3 - Compartment sink
Redbook (Temps, Master Sanitation, Ice Machine
Dates, Monthly ROR & action plan) Employee Hand Sink
Utility Closet
Equipment /
Dunkin Donuts Baskin Robbins

Donut / Muffin / Fancies / Bagel Display Cake Display Cases

Coffee Grinder + Calibration Cake Order Form
Brewer + Calibration Walk-in Freezer
Flavor Shot + Calibration Waffle Maker
Sugar Dispenser + Calibration Dipping Cabinets
Dairy Dispenser + Calibration Scooping Techniques
Coolatta/Island Oasis Machine Scoop Washing Wells
Hot Chocolate Machine Job Aids
Espresso Machine Employee Hand Sink
Bagel / Croissant Slicer 3 - Compartment sink
Bagel Toaster IF APPLICABLE: Softserve Machine
Microwave

14
 2 WEEKS WRITTEN NOTICE OF LEAVING
Date: ____________

Store Name: __________________________

Store Address: __________________________
Phone: __________________________
Fax: 773-326-3687

Dear __________________________,

I would like to inform you that I am voluntarily resigning from my position as

________________ for the __________________________, effective

__________________________.

Thank you for the opportunities for professional and personal development that you have

provided me. I have enjoyed working for the restaurant and appreciate the support provided me

during my tenure with the company.

If I can be of any help during this transition, please let me know.

Sincerely,

Sign: ________________________
Name: ________________________

15
 FINAL PAYCHECK AGREEMENT
I agree to the voluntary termination of my employment at the Dunkin Donuts at:

_____________________________________________________________________________.

My first day of employment was on ________________ & my last day of employment was on

________________. I confirm that my final work hours were __________ for pay period

___________________________________________and I have received the full payment on

_________________________________ (DATE).

___________________________________________ (Employee Name)

___________________________________________ (Employee Signature)

___________________________________________ (New Address, if applicable)

___________________________________________ (Manager Name)

___________________________________________ (Manager Signature)

___________________________________________ (Date)

*This document, including any attachments, is for the sole use of the addressee(s) to whom it has

been reviewed with, and may contain information that is confidential or legally protected. If you

are not the intended recipient or have received this message in error, you are not authorized to

copy, distribute, or otherwise use this message or its attachments. ALL INFORMATION IS

CONFIDENTIAL! DO NOT SHARE ANY INFORMATION WITHOUT THE WRITTEN

PERMISSION OF THE PANDYA NETWORK.

16
 ENROLLMENT / CHANGE FORM

Addition Change Termination Reason: _______________________ 01/01/2018

Effective Date ___________
If change or termination, complete only Employee’s Name, Social Security Number, and the Change details.
Termination date includes last day of coverage.
EMPLOYEE INFORMATION
Employee Name Sex Date of Birth Social Security Number
Last First MI
M F / / - -
Employee Home Address Home Telephone
Street/Apt. City State Zip + Four County
( ) -

Mailing Address ( if Different From Home Address) Business Telephone

( ) -
Status Marital Status Coverage Coverage: Check the box to select your Medical and Dental plans
❏ Active ❏ Single ❏ Employee Only Medical:Premium Quality Value HSA MEC NONE .
❏ COBRA ❏ Married ❏ Employee + One
❏ Retired ❏ Family Dental: Premium Quality NONE
Relation To If other insurance, Please
Employee If he / she is List Name of Other Insurance
List Full Name of Your Eligible 1-Spouse Date Social Handicapped or Carrier & Type of Coverage
Dependents 2-Child <26 Gender of Security Disabled (Medical, Dental) for each
years of age (M or F) Birth Number indicate H or D dependent with effective
3-Stepchild with effective dates
4-Other date
1
/ / - -
2.
/ / - -
3.
/ / - -
4.
/ / - -
5.
/ / - -
6.
/ / - -

Will this plan replace existing coverage? Yes No If yes, please provide a Certificate of Prior Health
Insurance Coverage (HIPAA certificate) to your employer as soon as you receive it from your prior insurer.
I verify that this information is true to the best of my knowledge. I authorize my employer to Is employee eligible for Medicare?
deduct from my pay any required contributions and understand that my enrollment will
❏ Y ❏ N Effective Date _____
continue until the Plan renews or I experience a qualifying event. Please see Human
Is spouse/dependent eligible for
Resources for additional information. Medicare?
__________________________________________ ________________
❏ Y ❏ N Effective Date__________
Employee Signature Date
THIS SECTION TO BE COMPLETED BY EMPLOYER: EMPLOYER (OR PLAN SPONSOR) STATEMENT:
Employer Name: Hire Date Effective Date
National DCP, LLC. / / 01 / 01 / 2018
PC# (Required) Employee Title
Employer Authorized Signature:

Print Name: Date: Telephone

Ravi Pandya 12 / 12 / 2017 ( 773 ) 745 - 9767
Mail to: CBA Blue, P.O. Box2365 South Burlington, VT 05407-2365 CBA Blue FAX NUMBER 802-862-7661
Fax to: CBA Blue Eligibility Department
 WAIVER OF COVERAGE FORM

EMPLOYEE NAME (Please Print):

WAIVER OF GROUP MEDICAL COVERAGE (Please Check One):

I waive my employer’s group health insurance coverage for myself and dependents (if any).

I am enrolling in my employer’s group health insurance coverage but I am waiving coverage for my dependents (if any).

WAIVER OF GROUP DENTAL COVERAGE (Please Check One):

I waive my employer’s group dental insurance coverage for myself and dependents (if any).

I am enrolling in my employer’s group dental insurance coverage but I am waiving coverage for my dependents (if any).

REASON FOR WAIVER OF GROUP COVERAGE (Please Check One):

Coverage through spouse’s employer:

Employer Name:_________________________________________________________________

Insurance Company:______________________________________________________________

Other reason (please explain)

___________________________________________________________________________________________

___________________________________________________________________________________________

____________________________________________________________________________________________

EMPLOYEE STATEMENT:

As a result, I waive my, and/or my dependents’ (if any) eligibility to enroll in my employer’s group health plan(s) at this time.
I understand that I and/or my dependents may enroll under these plans in the future only within 30 days from loss of other
group coverage or at the time of my employer’s annual open enrollment.

___________________________________________ __________________________________________
EMPLOYEE SIGNATURE DATE