Benefit Associates LLC - Customer Services

Please fill in the information requested below.

Customer Service - Terminate an Employee

Your Name

Company Name

Preferred Method of Contact (Provide one)

Phone Number

() -

Who is Being Terminated:

Provide the names, SSN and date of birth of who is being terminated from the plan(s):
EMPLOYEE
Name:	SSN://	DOB:
SPOUSE
Name:	SSN://	DOB:
CHILD
Name:	SSN://	DOB:
CHILD
Name:	SSN://	DOB:
CHILD
Name:	SSN://	DOB:
CHILD
Name:	SSN://	DOB:
CHILD
Name:	SSN://	DOB:

Date of Employment Termination

Date of Coverage Termination

Please provide most recent known address including zip code:

Reason For coverage termination:

Coverage to be terminated:

	Medical		Life/ Voluntary Life
	Dental		Disability