Regence BlueShield
1800 Ninth Avenue
Seattle, Washington 98111
Mail to: PO Box 1106
Lewiston, Idaho 83501
Fax to: 1-866-303-5117
REQUEST FOR TERMINATION
1. Please print in black ink. Incomplete and/or illegible information may result in delayed processing.
2. This form must be signed and dated by an Authorized Group Contact or it will be returned.
3. Use the fax number or mailing address at the top of this form and return it to the attention of the Membership Administrator indicated on your bill.
SECTION 1 – GROUP INFORMATION
Group Number Group Name
SECTION 2 – EMPLOYEE AND DEPENDENT TERMINATION INFORMATION
Please complete each section below to remove an employee or his/her dependent(s) from Medical and/or Dental coverage.
Employee or Dependent Name Date of Birth Reason for Termination Last Date of Coverage* Coverage to Terminate
1.
Medical
Dental
2.
Medical
Dental
3.
Medical
Dental
4.
Medical
Dental
5.
Medical
Dental
6.
Medical
Dental
SECTION 3 – AUTHORIZED SIGNATURE
This conrms that any employee and/or dependent for whom retroactive termination for administrative delay is requested had no expectation of coverage and paid no
premium after the requested termination date.
Signature of Authorized Group Contact: _______________________________________________________ Signature Date: ____________________
Printed Name of Authorized Group Contact: ____________________________________________________
*Last date of coverage is typically the last day of the month (not the last day of work) except, e.g., if your contract oers mid-month terminations, or on the date
of an employee/dependent’s death.
FORM 5252WA (E. 11/17) v2 *F5252.Xwa0EN11170101* *F5252.XWA0EN11170101*
