COBRA Cancellation Form

{BUSINESS NAME}

{ADDRESS}

{CITY, STATE, ZIP CODE}

Phone:   {NUMBER}    

Fax:   {NUMBER}

{EMAIL}

 

{DATE}

 

{EMPLOYEE NAME}

{ADDRESS}

{CITY, STATE, ZIP}

 

RE: Certification of Cancellation of Dependent Health Coverage

 

 

Dear {EMPLOYEE NAME}

 

 

Your enrollment for the {ENTER YEAR} Plan Year stated that you wanted to drop health coverage for one or more of your dependents.   Please fill out the enclosed form to confirm the cancellation of dependent coverage.   If you are dropping more than one dependent, and if you are dropping them for different reasons, you must use a separate sheet for each reason.   This form must be returned to {ENTER PLAN ADMINISTER NAME}, our plan administer, within 14 days.

 

If you have any questions, please contact {ENTER PLAN ADMINSTER NAME} at {ENTER CONTACT INFORMATION}.

 

 

Sincerely,

 

 

 

{NAME}

{POSITION}

{BUSINESS NAME}

 

Enclosure

 

 

 

 

 

 

 

Certification of Cancellation of Dependent Health Coverage

 

Return form within 14 days to:

{PLAN ADMINISTER NAME}

{BUSINESS NAME}

{ADDRESS}

{CITY, STATE, ZIP CODE}

Phone: {INSERT NUMBER}    

Fax: {INSERT NUMBER}

Email: {INSERT EMAIL}

 

 

 

Please indicate below (4) the reason for coverage cancellation:

Å"                                 Dependent(s) no longer classified as "dependent" under group health plan

Å"                                 Dependent(s) covered under other plan

Å"                                 Dependent(s) entitled to Medicare benefits

Å"                                 Change in custody or residence of dependent(s)

Å"                                 Death of dependent(s)

Å"                                 Decision to change benefits elections

Å"                                 Other (please specify) ____________________________________________

 

________________________                       _______________

Employee Signature                                                           Date

 

____________________________       _______________________   ______________            

Dependent Signature                                                       Print Dependent Name Date

(other than minor)