HAA Cancellation Request Form

Member Cancellation Request Form

For cancellations of membership in HAA or additional supplemental membership products.
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*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
HAA Products to Cancel (select all that apply)

HAA MembershipOptional a la carte Benefit Boost Subscription Product
Reason for Cancellation and Comments*
Refund Policy: If you are not completely satisfied with your HAA Membership Product, please call your Personal Member Concierge at 866-438-4274. We will be happy to issue a complete refund of membership dues within the first thirty (30) days. We want you to be 100% satisfied with your HAA benefits and services. Please be aware that premium & dues can’t be refunded if a claim was filed.

Note: This membership is separate from any other insurance or supplemental products you have purchased. Please contact your agent for any products other than a HAA Membership, HAA Gap Membership Products, and the a la carte health and wellness non-insurance Benefit Boost Subscription Products.

If you are canceling, please make sure to cancel using the member cancellation phone number at 866.438.4274 or this cancellation form located at healthyamericaassociation.com/billing.html. Please do not cancel through your agent. Cancel directly with your Personal Member Concierge to make sure your cancellation request is handled promptly and correctly.
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Member Cancellation Request Form