Terminate Coverage for Employees and/or Dependents 
All lines of coverage will be terminated unless you note a specific benefit is being terminated while another benefit plan stays in force.

Please follow this link for IMPORTANT information about COBRA regulations and to notify us which COBRA regulations apply to your group.


Who is submitting this form?

In case we have questions on this deletion, please provide your information.

 




Which group is the employee or dependent being removed from?

Client ID: (ex: 123456-0)


Name of the Group or Business that these changes are being submitted for:

Requested Deletion
Action requested:


Please indicate the reason for this termination of coverage:


Enter the coverage End Date:

Coverage can only be terminated at the end of the month. Credit can only be given for the current month.

  

Enter the last 4 digits of the employees Social Security Number or the Member ID number located on your invoice.
xxxx-xx-____ or DVINS12345 
 

If deleting just dependents, Please list the name and birth date of the dependents to be deleted.


Please give us any further information you feel is necessary to process your request in the memo below.
 
Cal-COBRA: NO COBRA form will be sent unless you indicate that you are subject to the CAL-COBRA regulations and a form needs to be sent (see above)

 
Address


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