BSG Inc

Employee Termination, Cancellation or Changes

Plan admins: Submit one request per employee. Verify the Company Client ID and Employee ID against your roster, enter the employee’s name, and provide the relevant dates and a brief explanation.

Terminate Employee: Report that employment or employer ICHRA participation is ending. Enter the termination date and benefits end date. This does not automatically cancel the employee’s individual insurance policy. Requests after the 20th may affect the following month’s billing; contact BSG Support.

Cancel Coverage: Request cancellation of insurance. The employee must complete the cancellation form sent by BSG to finalize the request.

Changes (Medicare, life event—got married, had a child, divorce, move, or other coverage change): Request a review with a health advisor. Describe what changed and when. Submitting this form does not confirm a coverage change or effective date.

Questions? [email protected] | 930-212-3143

How can we help today? *

Terminate Employee

Employee wants to Cancel

Employee Needs to Make Changes

First Name *

Last Name *

Phone *

Email *

Organization *

Name of Admin Submitting this Form *

Anything Else We Should Know?

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Company Client ID *

Shown on your BSG portal dashboard.

Employee ID *

Prefilled from the employee roster. Verify this ID before submitting.