Disenrollment Portal

Please be advised this form is only to be completed by those authorized to make changes to employee benefits!

Company Name

Name of person completing this form

First Name

Last Name

Email address of person completing this form

Employee's Name

First Name

Last Name

Employee's DOB

YYYY

Last day worked

YYYY

Reason for request

If other, please indicate

Effective Date of Change

On the first day of:

COBRA eligible?

Yes

Employee's Personal Email Address

Please provide email address if COBRA eligible