BEST Life and Health Insurance Company

Employee Coverage Termination Form
Please complete this form to terminate coverage for an employee and/or the employee's dependents.

Employee Information

Company Name *

Enter company name

Customer # *

Enter your customer #

Employee Name - Last

First

M.I.

SS#

Terminate Coverage for

Select One
If dependent provide name(s)

Terminate coverage for (check all that apply) *

Dental Vision Life STD

COBRA:

Requested Term Date

Reason for Termination of Coverage

Select reason

Last day of full-time employment

Please Explain

Employer Signature * Enter your full name here

Employer Email * Enter employer email

Check for authorization

EMPLOYEE'S AUTHORIZATION *

You accept all terms above and certify that all information supplied above is correct.

Enter Security Code Shown Above:

Please enter code