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I understand that THIS FORM REVOKES ANY PREVIOUS AUTHORIZATION FORM ONLY WITH RESPECT TO THE PERSON S NAMED ABOVE. IF I DECIDE TO REAUTHORIZE THIS PERSON S I WILL NEED TO SUBMIT A NEW COMPLETED AUTHORIZATION FORM TO THE BENEFITS OFFICE. CANCELLATION WILL TAKE EFFECT ONCE THE BENEFITS OFFICE RECEIVES THIS FORM. Social Security Print Name of Member National Elevator Industry Health Benefit Plan 19 Campus Blvd. Suite 200 Newtown Square PA 19073 1-800-523-4702 CANCELLATION OF AUTHORIZATION FORM...

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What is print name of member?

Print name of member is the full name of the individual who is a member of a specific organization or entity.

Who is required to file print name of member?

The person or entity responsible for maintaining records of members is required to file print name of member.

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Print name of member can be filled out by writing the complete name of the member in the designated space on the form or document.

What is the purpose of print name of member?

The purpose of print name of member is to accurately identify the individual who is a member of the organization, entity, or group.

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The information reported on print name of member must include the full legal name of the member.

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