CalChoice Employee Termination Notification

Fax completed form to (714) 558-8000 or E-mail to: memberprocessing@calchoice.com

This form can terminate upto three employees.

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.*

Employee First Name*

Employee Last Name*

Employee Social Security*

Last Day Employed or Eligible (MM)*

Enter Month

Last Day Employed or Eligible (DD)*

Enter Day

Last Day Employed or Eligible (YYYY)*

Enter Year

Reason*

Resignation of employmentInvoluntary employment terminationHours reduced - no longer eligibleDeceased

Employee Last Name

Employee First Name

Employee Social Security

Last Day Employed or Eligible (MM)

Enter Month

Last Day Employed or Eligible (DD)

Enter Day

Last Day Employed or Eligible (YYYY)

Enter Year

Reason

Resignation of employmentInvoluntary employment terminationHours reduced - no longer eligibleDeceased

Employee Last Name

Employee First Name

Employee Social Security

Last Day Employed or Eligible (MM)

Enter Month

Last Day Employed or Eligible (DD)

Enter Day

Last Day Employed or Eligible (YYYY)

Enter Year

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 the Assurity Life, AD&D and Waiver of Premium Claim Information (Form 01-878-01114).

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

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

Print Name

Authorized Group Contact Signature

Today's Date (MM)

Enter Month

Today's Date (DD)

Enter Day

Today's Date (YYYY)

Enter Year

General Guidelines

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. • Written notification must be received within 30 days of the event.
CaliforniaChoice 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

This document should be faxed to CaliforniaChoice for immediate attention

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

Fax to (866) 412-9280

Use the Preview 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 CaliforniaChoice.

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.