ChoiceBuilder Employee Termination Notification

Company Name

GROUP

Complete this form when there is a termination of employment, reduction of hours or loss of life. Coverage will end on the last day of the month following each event. Should the event occur on the last day of the month, coverage will terminate same day.*

Name

Employee First NameEmployee Last Name

Employee Social Security

Last Day Employed or Eligible (MM/DD/YYYY)

Reason:

Resignation of employmentInvoluntary employment terminationHours reduced - no longer eligibleDeceased

Name

Employee First NameEmployee Last Name

Employee Social Security

Last Day Employed or Eligible (MM/DD/YYYY)

Reason:

Resignation of employmentInvoluntary employment terminationHours reduced - no longer eligibleDeceased

Name

Employee First NameEmployee Last Name

Employee Social Security

Last Day Employed or Eligible (MM/DD/YYYY)

Reason:

Resignation of employmentInvoluntary employment terminationHours reduced - no longer eligibleDeceased

**Involuntary termination of employment includes but is not limited to layoffs, job elimination and termination for cause. *** If your group offers Life coverage you will also need to submit either the Assurity Life, AD&D and Waiver of Premium Claim Information (Form 01-878-01114) or MetLife Life Claim Form.

Form MUST be signed and dated by an authorized group contact on file with ChoiceBuilder in order for the termination request to be processed.

If your company offers Life Insurance through ChoiceBuilder, it is your responsibility to notify terminated employees of their conversion rights. The life conversion information is available at www.choicebuilder.com

Authorized Group Contact Signature

Print Name

Date

Please do not send a cancellation request prior to the actual last day of employment or eligibility.
Coverage will cease at the end of the month following the last day of employment or eligibility. In some cases, termination of employment and termination of coverage will be the same day.
Written notification must be received within 30 days of the event.
ChoiceBuilder will only give retroactive credit if notification was received within the guidelines provided.
Voluntary termination of coverage for employees and/or dependents must be submitted on a change request form. (Coverage will cease at the end of the month following receipt of a completed form. If received on the last day of the month, coverage will end same day.)

Dependent qualifying/triggering events should be submitted on a dependent qualifying event form. (Coverage will cease at the end of the month following the event provided written notification is given within 60 days of the qualifying/triggering event.)

This document should be emailed or faxed to ChoiceBuilder for immediate attention

E-mail completed form to memberprocessing@choicebuilder.com or

Fax to (866) 412-9280

Use the Print button to Print and Email or Fax.

Please email us at holisticeb@gmail.com

if you would like us to send the

Termination Form to ChoiceBuilder.

Save and Continue Later if you'd like to start the form on your computer and sign with your phone. You'll receive a link by email to complete the signature and submit it later.

General Guidelines