Group Health Employee Termination Notice
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Employer:
*
Group Number
*
Employee Name:
*
First Name
Last Name
ID Number:
Termination Effective Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Person's Losing Coverage:
*
Employee
Employee's Spouse
Dependent Child(ren)
Please complete for each:
*
Qualifying Event:
*
Voluntary Termination
Involuntary Termination
Reduction of Hours
Medicare Entitlement
Divorce/Legal Separation
Death of Employee
Dependent 26th Birthday
Termination Approved By
*
First Name
Last Name
Title
*
Signature
*
Continue
Continue
Should be Empty: