Term Employee

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Company Name

Requestor's Name

First Name

Last Name

Policy Term reason

Left Employment Turned Part-Time Obtained Other Coverage Other

Reason

Other

Event Date

Last day of Employment
Last day of full-time work;
Day other coverage was obtained

Term the following coverages

All

Health

Dental

Vision

Life

STD/LTD

other

Special Instructions / Notes

I confirm that I am an owner, officer, or authorized representative of this company and am authorized to request this change. I understand that submitting this form may terminate insurance coverage for the employee(s) listed, including any covered dependents, as of the effective date indicated. I have verified the information is accurate and understand this action may not be reversible.

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This form is secure and encrypted — any personal and health information you enter is transmitted and stored using encryption to keep it protected. Please complete it only on a device you trust.

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