Clone of 2025 Employee Termination Submission Form

Mi-Choice powered by GoWell Employee Termination Submission Form

Please complete the information below to have your employee terminated in the ICHRA platform and receive communications regarding ICHRA, including how to retain their individual coverage should they wish to do so. For more information, go to your Admin HUB. If you need any assistance, please send us an Assistance Request Form (ARF) through the Admin HUB. Thank you!
Name of Administrator Submitting a Termination*
Administrator Email*
example@example.com
Company Name*
Employee Details:
Employee Full Name*

First NameLast Name
Date of Termination*

MonthDayYear
Add the termination date for calculations of termination date of coverage and payment.
Employee Personal Email*
Reason for Termination
If OTHER, please state reason:
By my signature below, I acknowledge that I am authorized to submit this employee termination request. I hereby authorize Mi-Benefits to terminate the above mentioned employee in my company's ICHRA platform therby cancelling monthly premium payments effective the last day of the month in which employee was terminated.
Signature*

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Should be Empty:

Mi-Choice powered by GoWell Employee Termination Submission Form