I acknowledge that I have been offered the opportunity to purchase health coverage from Creactiva LLC thru Blue Cross & Blue Shield of Alabama for myself and my dependents through my employer.

I decline enrollment at this time because:

If you are declining enrollment for yourself or dependents (including your spouse) because of other health care coverage, you may enroll yourself or your dependents in this plan prior to the next open enrollment period (under certain circumstances). To do this, you must have involuntarily lost your other coverage and we must receive your enrollment application within 30 days after your other coverage ended. Additionally, if you have new dependents as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and dependents, provided we receive your completed enrollment application within 60 days after the marriage, birth, adoption, or placement for adoption.