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Termination of Coverage Form Employer is to complete this form to terminate coverage for an employee and/or the employees dependents. See Page 2 for more information. EMPLOYEE INFORMATIONSubscriber
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What is Termination of Coverage Form?

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Termination of coverage form is a document used to officially end an individual's insurance coverage.
The individual whose coverage is ending or the employer providing the coverage may be required to file the termination of coverage form.
The termination of coverage form can usually be filled out online or submitted through mail, following the instructions provided by the insurance provider.
The purpose of termination of coverage form is to notify the insurance provider that an individual's coverage is ending and to cancel any future premium payments.
The termination of coverage form typically requires information such as the individual's name, policy number, effective date of termination, and reason for ending coverage.
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