Employee Benefit(s) Termination Form Request

Your Name (required)

Your Email (required)

Your Group/Company (required)

Employee to Terminate Benefit(s) (required)

Event Date of Termination (required)

Event Type (required)
Address ChangeAdoptionAnnulmentBecoming a Lawfully Present ResidentBecoming a U.S. CitizenBecoming a U.S. NationalBenefit Package Addition, Improvement, or CurtailmentBirthChange in Cost of CoverageCOBRA or State ContinuationCommencement of Military LeaveCourt OrderDeathDivorceEmployment Status ChangeEnrolled in Other CoverageFamily and Medical Leave (FMLA)Gain Custody of DependentGain Dependent Eligibility StatusGain Eligibility Medicare/MedicaidGain Eligibility for Medicaid or CHIP SubsidyLegal SeparationLose Eligibility Medicare/MedicaidLoss of Medicaid or CHIP CoverageLoss of Dependent Eligibility StatusLoss of Other CoverageMarriageReturn from Military LeaveOther (Not COBRA Qualified)

Please list which plans you wish to terminate for each member (if terminating dependents, please list which dependents should be terminated on each plan) (required)