PLEASE NOTE:

If Terminate is selected, Ex-Employee will receive communication of how to keep their benefits by self paying. If submitting past the 20th of the month you will need to withhold or pay the following months bill for employee.

If Cancel is selected, Employee will receive a text with a Cancellation form to fill and sign. This has to be completed by them to finalize cancellation.

If Change Coverages is selected, employee will receive a text with a scheduling link to make those changes with their health advisor.

How can we help today? *

Terminate Employee

Employee wants to Cancel

Employee Needs to Make Changes

First Name *

Last Name *

Email *

Phone *

Organization *

Termination Date *

Benefits End Date *

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.