Cobra Benefits Termination Form PDF Details

When an employee is no longer working for a company, he or she will often need to fill out a Cobra Benefits Termination Form to ensure that their Cobra coverage is properly terminated. This form must be filled out and returned to the insurance company in order to stop any future premiums from being taken out of the former employee's paycheck. The form can be filled out either electronically or manually, depending on the insurance company's preference. There are a few things employees should keep in mind when filling out this form, such as making sure all required information is included and that they are aware of any cancellation fees. By understanding the ins and outs of this process, employees can ensure that their Cobra coverage is terminated correctly and without any headaches.

QuestionAnswer
Form NameCobra Benefits Termination Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescobra benefits termination form, discovery benefits cobra form, benefits cobra termination form, how to cancel cobra discovery benefits

Form Preview Example

COBRA Benefits Termination Form

This form is to terminate one or more benefits continued through COBRA.

If participating in ACH, please note Discovery Benefits needs to receive notification at least 15 days prior to the 1st of the month of your requested termination. If this form is received after that timeframe, Discovery Benefits cannot guarantee that the ACH payment for that month will be cancelled. However, if a payment is withdrawn, you will be refunded via check.

When terminating all benefits with an overpayment balance remaining, you will only receive a refund check if the amount is greater than $25.00. Lesser amounts are used by the employer who sponsors the group health plan to pay for plan administration expenses. Standard processing time for refunds is 15 business days from the date this completed form is received.

Step 1: Primary Qualified Beneficiary Information

*=Required Fields

-

*Primary Qualified Beneficiary Name (First, MI, Last)

*Social Security Number

 

 

-

*Previous Employer (Do not abbreviate)

-

*Day Telephone

-

Email Address

Step 2: Benefit Termination Information

Please specify the benefit(s) you are requesting to discontinue through COBRA. Please also indicate the effective date you are requesting coverage to terminate as well as the person(s) affected by the change.

 

 

*Benefits

 

*Effective Dates of Termination

*Person(s) Affected

 

 

 

 

(mm/dd/yyyy)

(PQB and/or Dependents)

 

 

 

 

 

 

 

Medical

 

 

 

 

 

 

 

 

 

 

Dental

 

 

 

 

 

 

 

 

 

 

Vision

 

 

 

 

 

 

 

 

 

Other (

 

)

 

 

 

 

 

 

 

 

Other (

 

)

 

 

 

 

 

 

 

 

Other (

)

 

 

 

 

 

 

 

 

If the reason for requesting termination is due to death of the former employee, divorce or legal separation from the former employee, or a dependent child’s ceasing to be a dependent, please use the COBRA Second Qualifying Event Form.

Step 3: Primary Qualified Beneficiary Certification

I understand my submission of this form is a request to terminate the specified benefit(s) indicated above. Further, I understand Discovery Benefits will contact me if my request to terminate coverage is denied for any reason.

*Primary Qualified Beneficiary Signature

*Date

 

 

 

 

 

*Spouse Signature (Only required if coverage is being terminated for the spouse but not the PQB)

*Date

How to Edit Cobra Benefits Termination Form Online for Free

Handling PDF files online is actually very simple with our PDF editor. Anyone can fill out cobra benefits termination form here effortlessly. The editor is consistently updated by our staff, getting new functions and turning out to be greater. To get the process started, take these easy steps:

Step 1: First, access the pdf editor by pressing the "Get Form Button" above on this webpage.

Step 2: With the help of our advanced PDF tool, you can accomplish more than just fill in blank fields. Edit away and make your forms appear faultless with customized text put in, or optimize the original input to excellence - all that supported by an ability to insert any kind of pictures and sign it off.

This PDF doc will require some specific details; in order to ensure accuracy and reliability, remember to consider the following guidelines:

1. While filling in the cobra benefits termination form, be sure to incorporate all of the essential fields in the corresponding section. This will help facilitate the process, which allows your details to be handled without delay and correctly.

Tips on how to fill in cobra termination form portion 1

2. The subsequent step is to submit the next few blanks: If the reason for requesting, Primary Qualified Beneficiary, Date, and Spouse Signature Only required if.

Step no. 2 of filling out cobra termination form

Those who work with this document often make some mistakes while completing If the reason for requesting in this part. Remember to re-examine whatever you enter right here.

Step 3: Right after going through your form fields, hit "Done" and you're good to go! After registering a7-day free trial account here, it will be possible to download cobra benefits termination form or send it via email without delay. The PDF file will also be easily accessible from your personal account page with your every single edit. At FormsPal, we aim to make certain that all of your details are kept private.

Cobra Benefits Termination Form isn’t the one you’re looking for?

Related Documents