Terminate Health Benefits for Employee

1

Your Contact Information* This field is required.In case we have questions

Name

Email

2

Employer* This field is required.What is your company name?

3

Reason for Termination* This field is required.Let us know the relevant qualifying event

Voluntary termination of employment

Involuntary termination of employment

Active employee dropping coverage

Reduction in work hours

Other

4

Qualifying Event Date* This field is required.Please provide last date worked for terminations; or date of qualifying event for still-active employees

5

Employee Name* This field is required.Please tell us who the employee terminating coverage is

Employee Name

6

Employee ID* This field is required.In case you have two employees with similar names

Last 4 of SSN

7

Were flex deductions withheld from final paycheck?* This field is required.We'll make sure the TPA account accrues correctly

Yes - all deductions

Yes - all except for commuter benefits

No - employee requested

No - we don't have a flex plan

Other (please explain in additional comments)

8

Does this employee need to update their address?Paperwork for Cal-Cobra/COBRA continuation coverage will be sent to the address on file

Street Address

Street Address Line 2

City

State

Zip Code

Country

9

Additional CommentsAnything else you need to let us know about this termination of benefits?

10

Upload Forms or Supporting DocumentsOnly if needed

Drag and drop files here

Select files to upload

11

File(s) Uploaded?Log in to Jotform to securely retrieve uploaded files