Membership Cancellation Instructions

On the Group Enrollment Form:


Section 1

  • Complete in full


 Section 3

  • Check the box that indicates the reason for your cancellation.
  • Complete the Date of Event box


 Section 6

  • 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.