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Loss of Coverage Statement Northeast Regional Office PO Box 26050 Leigh Valley PA 180026050 Midwest Regional Office PO Box 8012 Appleton WI 549128012 Western Regional Office PO Box 2454 Spokane WA
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What is loss of coverage statement?
Loss of coverage statement is a document that notifies the insurance company that an individual no longer has coverage under a specific insurance plan.
Who is required to file loss of coverage statement?
Employers, insurers, or plan administrators are required to file loss of coverage statement.
How to fill out loss of coverage statement?
Fill out the required information such as the name of the individual losing coverage, the reason for losing coverage, and the effective date of the loss.
What is the purpose of loss of coverage statement?
The purpose of the loss of coverage statement is to inform the insurance company of changes in an individual's coverage status.
What information must be reported on loss of coverage statement?
The name of the individual losing coverage, the reason for losing coverage, and the effective date of the loss must be reported on the loss of coverage statement.
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