Termination of Coverage Request

I am signing this Termination of Coverage Request so Teague Financial can initiate my process, but it is not guaranteed and it is my responsability.

Member Name*

Please terminate my coverage effective:

Of year:

Please upload your Current Health Insurance ID card:*

Signature Date*

Date

Member Signature*

I understand this is a member responsibility and is not managed or monitored by the insurance broker, Teague Financial Insurance Services. I understand that the carrier may require I call Member Services (using the member services phone number on the back of my ID card) to terminate coverage. Teague Financial strongly recommends each member confirms with the carrier directly to terminate coverage prior to their effective date. Teague Financial is not responsible or liable for duplicate coverage or duplicate premiums.

Would you like to receive a copy of your submission? If so, please insert your email:

Confirmation Emailexample@example.com