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Membership Cancellation Instructions
On the Group Enrollment Form:
- Complete in full
- Check the box that indicates the reason for your cancellation.
- Complete the Date of Event box
- If the subscriber is no longer employed, the Remitting Agent may sign the enrollment form on behalf of the employee
- If the subscriber is employed, but elects to cancel the coverage, the employee must sign the enrollment form.
Fax completed Group Enrollment forms to: