Mi-Choice powered by GoWell Employee QLE (Qualifying Life Event) Submission Form
Employee's typically only have 60 days from the date of a life event to make any changes to their coverage.
Name of Administrator Submitting a Termination
*
Administrator Email
*
example@example.com
Company Name
*
Employee
Details:
Employee Full Name
*
First Name
Last Name
Employee Email
*
Date of Life Event
*
/
Month
/
Day
Year
Add the termination date for calculations of termination date of coverage and payment.
Life Event
*
Please Select
Marriage
Divorce
Birth/Adoption
Child or Dependent turned 26
Loss of Coverage
Moved
Death
OTHER (please state reason)
If OTHER, please explain:
Examples of evidence to be provided by Employee to Enrollment Team and/or Carrier:
Marriage: Marriage certificate.Divorce: Court-issued divorce decree.Birth or Adoption: Birth certificate or adoption record.Death in the Family: Death certificate.Change of residence: One of the following showing your new address: utility bill, lease/mortgage statement, USPS confirmation, driver’s license, or government mail.Other Changes: A document that includes your name and confirms the date of the event. If your spouse lost coverage, please include a termination letter on official letterhead and a letter from the previous insurance company indicating the coverage end-date.
Submit QLE
Should be Empty: