Sample Medigap Cancellation Letter Page 2
Download a blank fillable Sample Medigap Cancellation Letter in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Sample Medigap Cancellation Letter with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Date
Name of Insurance Company
Company’s Mailing Address or PO Box
Company’s City, State, Zip Code
Re: Medigap Cancellation
I am sending you this written notice to request cancellation of my Medigap insurance policy
effective [insert cancellation date], as I am enrolling in a Medicare Advantage Plan. As mentioned
in the 2014 CMS “Medicare & You” Handbook, I understand that:
- By dropping my Medigap coverage to join a Medicare Advantage Plan, I may not be able
to obtain another Medigap policy in the future.
- If I had decided to keep my Medigap policy, I realize that my Medigap policy cannot be used
to pay Medicare Advantage Plan co-payments, deductibles, and premiums.
Please send me written confirmation within 30 days that the cancellation has been put into effect.
Thank you for your prompt attention to this matter.
Sincerely,
[Member Signature]
Member Name:
Member / Policy #:
Member Mailing Address:
Member City, State, Zip Code:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Letters