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.
In case we have questions on this deletion, please provide your information.
Client ID: (ex: 123456-0)
Name of the Group or Business that these changes are being submitted for: