Submit by Email
Print Form
Call/Fax:
Tel: 888‐292‐0272
FAX: 312‐416‐2860
Please Complete and return via FAX or E‐mail
E‐mail:
FORM INSTRUCTIONS
Please complete the form and submit to Allied within 30 days of a member coverage termination.
EMPLOYER INFORMATION
Group Name:
Group Number:
EMPLOYEE INFORMATION
Employee Name:
Last
First
Middle Initial
Employee Social
Employee Date of Birth:
Security Number:
MM
DD
CCYY
Employee Address
City
State
Zip Code
TERMINATION INFORMATION
☐ End of Month
Date of
Date of Qualifying
th
☐ 14
of Month (
Only applies if your Group Effective
Insurance Term:
Event/Termination:
th
MM
DD
CCYY
date is the 15
of the Month)
Qualifying Event Reason (choose one)
☐Employee’s Termination or
☐Employee’s Death
☐Spouse’s Divorce or Legal
☐Employee’s Reduction in Hours
Employee’s Layoff
Separation from Employee
☐Dependent Child Ceasing to
☐Medicare Entitlement
☐Certification Only
☐Open Certificate (check only if no
Qualify Under the Plan
termination date exists)
If a Termination of Employment was the Qualifying Event, please indicate whether the Termination was Voluntary or Involuntary:
☐Involuntary
☐Voluntary
TERMINATION OF MEDICAL COVERAGE REQUEST
Birth Date
Social Security
Effective Date
Employee Name
Relationship
Gender
Coverage Type
MM/DD/CCYY
Number
MM/DD/CCYY
☐M ☐F
☐Med
Employee
Dependent Name(s)
☐Spouse
☐M
☐F
☐Med
☐Child
☐Child
☐M
☐F
☐Med
☐Child
☐M
☐F
☐Med
☐Child
☐M
☐F
☐Med
AUTHORIZATION
I certify that the above information is accurate. If applicable, I authorize Allied Benefit Systems, Inc. to notify those individuals whom I have certified of
their COBRA rights and creditable coverage.
_______________________________________________
_____________________________________
Signature of Authorized Company Representative
Date
For Office Use Only:
Date Processed: / /20
By:_______________________________________