Allied Benefit Systems Summit Insurance Services Termination Form

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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:_______________________________________
 

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