FIND A CHURCH

REQUEST TO CANCEL BENEFITS

MM slash DD slash YYYY
Please use this form to request the cancellation of an employee’s insurance coverage. Notification after 30 days of the end of benefits may result in additional expenses. This notification is important as it affects insurance benefits for which the congregation may be held accountable.

IMPORTANT INFORMATION:

Address of Congregation:
Name of Insured employee:
Cancellation Due to:

MM slash DD slash YYYY
MM slash DD slash YYYY
(if applicable)
New home address:
(if applicable)
(if applicable)
(if applicable)

Which of the following benefits are to be cancelled? :

Health Insurance
Group Life Insurance (Lay employees only)
Disability Insurance:
Disability Insurance Type:

AUTHORIZATION/OFFICIAL’S SIGNATURE:

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