Form Enr-237 - Authorization To Cancel Highmark Small Business Coverage printable pdf download

Form Enr-237 - Authorization To Cancel Highmark Small Business Coverage

For Highmark & Association Use Only

Association Received Date

Highmark Received Date

AUTHORIZATION TO CANCEL HIGHMARK SMALL BUSINESS COVERAGE

Thank you for your enrollment in a Highmark Small Business program. It has come to our attention that you wish to

terminate your Small Business coverage at this time. To do so, we ask that you complete and sign this Authorization to

Cancel Highmark Small Business Coverage form and return it as soon as possible to

Please note that if you obtained your Highmark coverage through an association, you will need to send this

form to both Highmark and the association. The association is required to send a copy of this form to Highmark

for cancellation. This requirement is in addition to specific Highmark/Third Party Administrator cancellation

procedures.

By signing below, I hereby authorize that my Small Business coverage may be terminated (check all that apply):

Medical Coverage

HRA

Vision Coverage

FSA

Dental Coverage

HSA

Client Name:

Client Number:

Group Number(s):

Agency Name:

Requested Cancellation Date:

(Please note that coverage will be cancelled on the first of the month following the postmarked date of this form. Any

premium payment made for coverage beyond the cancellation date will be refunded. Retroactive employer

cancellations are not permitted. Any premium payment due to Highmark for month(s) prior to termination will be

collected.)

Reason for termination (check all that apply):

Cost

Obtained Other Coverage (Carrier’s Name:)

Other:

(please specify)

Employer’s Name:

Title:

Employer’s Signature:

Date:

ENR-237 (10-14)

Highmark Blue Cross Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association

Form Enr-237 - Authorization To Cancel Highmark Small Business Coverage