Employee Coverage Termination Form

Please complete this form to terminate coverage for an employee and/or the employee's dependents.

 

PLEASE NOTE: Do not make adjustments on your bill for terminated employees or dependents. When termination of coverage is processed, the adjustment will appear on your next bill.

 

* Denotes a required field
Company Name *
Required field
Customer # *
Required field
Employee Name - Last
First
Middle Initial
SS#

 

Terminate Coverage for:
Check one:





If dependent provide name(s)


Terminate coverage for (check all that apply):

Medical/Rx
Dental
Vision
Life
Short Term Disability
COBRA:

Offer COBRA
Term COBRA
Requested Term Date:


 

Reason for Termination of Coverage (check one):
. .
Last day of full-time employment
Please Explain
Death     Marriage    Divorce     Other:
Employer Signature *
Required field
Employer Email Address *
Required field

 

By placing a check-mark in the "Employer Authorization" box below, I certify that the information on this
form is correct.

A value is required.

Please make a selection. Required authorizationEMPLOYER'S AUTHORIZATION (YOU ACCEPT ALL TERMS ABOVE AND CERTIFY THAT ALL INFORMATION SUPPLIED ABOVE IS CORRECT)

 

security code

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