Cancellation Request Form

Date

Today's date*

MonthDayYear

Original Date of Purchase

MonthDayYear

Request of Cancellation*

Cancellation for future drafts onlyCancellation and Refund (first 30 days)

Full Name*

First NameLast Name

E-mail*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Choose the plan options that you want to cancel. You can cancel all plans or just specific plans. If you are cancelling specific plans, make sure that you indicate what that plan name you want to cancel in the Comments Section.

UBA Products to Cancel (select all that apply)

UBA MembershipOptional Supplemental Insurance PlansAll Plans Enrolled

HAA Products to Cancel (select all that apply)

HAA MembershipOptional Supplemental Insurance PlanAll Plans Enrolled

Other Products to Cancel (select all that apply)

VSP Individual Vision PlanBenefit Boost SubscriptionAll Plans Enrolled

Reason for Cancellation and Comments*

30-Day Satisfaction Assurance Policy (Refund Policy)

If for any reason you are not completely satisfied with your enrollment, just notify us anytime up to thirty (30) days after your Effective Date to cancel and receive a full refund of all dues, premiums, or fees paid.

Notice: for any enrollment in a program or plan that provides insurance benefits or coverage, enrollment costs cannot be refunded if an insurance claim has been filed.

Note: Plans are drafted monthly until cancellation. It is your responsibility to check the transactions occurring on your account every month and to cancel with us when desired. Every month we pay for the membership services and the insurance premiums for any applicable group insurance programs on your behalf, whether you use the membership services or file a claim with the group insurance programs

Signature

Please verify that you are human*