Docstoc

Termination-Form

Document Sample
Termination-Form Powered By Docstoc
					                                                                                                                                             Allied Benefit Systems, Inc.
                                                                                  Please complete                                            208 S. LaSalle, Suite 1300
                                                                                  and return via fax                                         Chicago, IL 60604
                                                                                      or e-mail                                              312/906-8080 *4 (tele)
                                                                                                                                             312/416-2860 (fax)
                                                                                                           follow link to e-mail              pamiller@alliedbenefit.com



                                                               COBRA FORM

Group Name:                               Wellness Insurance Network (WIN)                                                                                                 Group # A01195
Employee Name (Last, First, Middle Initial)

Employee Social Security Number

Date of Birth

Employee Address


                                                            Termination Information

Employee Date of Hire                                                                     Date of Qualifying Event:
Date Ins Waiting Period Began (if different):                                             Date of Insurance Term:
Effective Date of Insurance:



Qualifying Event Reason:

           If a Termination of Employment was the Qualifying Event, please indicate whether the Termination was Voluntary or Involuntary:

                                                                                          Involuntary              Voluntary

Employee Type of Coverage                                        Medical                  Dental


                                           TERMINATION OF MEDICAL/DENTAL/RX COVERAGE REQUEST
DEPENDENTS:                     Name                     Sex         Date of Birth        SSN#                   Effective Date                                 Coverage Type Must be Checked

Spouse                                                                                                                                       Medical              Dental
Child                                                                                                                                        Medical              Dental
Child                                                                                                                                        Medical              Dental
Child                                                                                                                                        Medical              Dental
Child                                                                                                                                        Medical              Dental




         FSA:                                   (Date of last contribution)               Monthly FSA Contribution:                    $                              -

                  I certify that the above information is accurate and authorize Allied Benefit Systems, Inc. to notify those individuals whom I have certified of their
                  COBRA rights and creditable coverage.



                  Signature of Authorized Company Representative                                                               Date

				
DOCUMENT INFO