Group Health Employee Termination Notice

Group Health Employee Termination Notice
Date

MonthDayYear
Employer: *
Group Number*
Employee Name:*

First NameLast Name
ID Number:
Termination Effective Date:*

MonthDayYear
Person's Losing Coverage:*

EmployeeEmployee's SpouseDependent Child(ren)
Please complete for each:*
Qualifying Event:*

Voluntary TerminationInvoluntary TerminationReduction of HoursMedicare EntitlementDivorce/Legal SeparationDeath of EmployeeDependent 26th Birthday
Termination Approved By*

First NameLast Name
Title*
Signature*
Should be Empty: