Company Name
Employee Termination
Notification Form
For Termination of Employment, Reduction of Hours, Loss of Life
Complete this form when there is a termination of employment, reduction of hours or loss of life. Coverage will end on the last day of the month
following each event.*
**Involuntary termination of employment includes but is not limited to layoffs, job elimination and termination for cause.
If your company offers Life Insurance through CaliforniaChoice , it is your responsibility to notify terminated employees of their conversion rights. The life
conversion information is available at www.calchoice.com
Form MUST be signed and dated by an authorized group contact on file with CaliforniaChoice in order for the termination request to be processed.
This document should be faxed to CaliforniaChoice for immediate attention
NOTE: MUST have birth date, zi
p
code and date of hire to
p
rocess this
q
uote.
(1 of 1)
Please do not send a cancellation request prior to the actual last day of employment or eligibility
Coverage will cease at the end of the month following the last day of employment or eligibility
Written notification must be received within 30 days of the event
CaliforniaChoice will only give retroactive credit if notification was received within the guidelines provided
Voluntary termination of coverage for employees and/or dependents must be submitted on a change request form. (Coverage will
cease at the end of the month following receipt of a completed form.)
Dependent qualifying/triggering events should be submitted on a dependent qualifying/triggering event form. (Coverage will cease at the end of the
month following the event provided written notification is given within 60 days of the qualifying/triggering event.)
General Guidelines
Employee Last Name Employee First Name
1
Employee Social Security #
Reason
Resignation of employment
Involuntary employment termination**
Hours reduced - no longer eligible
Deceased
Employee Last Name Employee First Name
2
Employee Social Security #
Reason
Resignation of employment
Involuntary employment termination**
Hours reduced - no longer eligible
Deceased
Employee Last Name Employee First Name
3
Employee Social Security #
Reason
Resignation of employment
Involuntary employment termination**
Hours reduced - no longer eligible
Deceased
Authorized Group Contact Signature Print Name
721 South Parker, Suite 200, Orange, CA 92868
(
800
)
558-8003 www.calchoice.com
Group #
*Last Day Employed or Eligible (MM/DD/YYYY)
/ /
*Last Day Employed or Eligible (MM/DD/YYYY)
/ /
Today's Date (MM/DD/YYYY)
/ /
*Last Day Employed or Eligible (MM/DD/YYYY)
/ /
Fax completed form to (714) 558-8000 or E-mail to memberprocessing@calchoice.com
®
CC 0420A 9/2019 Eff. 1/1/2020
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
19678
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