Employee Benefit(s) Termination Form Request

In order to submit a request for a Benefit Termination for an Employee, please complete the below form in its entirety in order to terminate coverage. If terminating coverage for multiple employees, please submit one form for each employee. Please note you may only terminate coverage 30 days retroactive. If you require further assistance, please contact us here. This form is meant to be completed if an employee is remaining active, and the only reason for termination is to remove one or multiple benefits. If your employee has left your company, the company administrator must terminate the employee in Ease.

Employee Benefit 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)

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)