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Terminating Coverage
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Large Group 3+
Life Insurance and Accidental Death & Dismemberment (AD&D)
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Small Group 1-2
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Changing Employee's coverage
Terminating Employee Coverage
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Terminating Employee Coverage
Terminating Employment
Plan Administrator completes
Notice of Change Form
Email or fax a copy of this form to
csc@morneaushepell.com
or fax to 1-877-494-0109.
Retain the original for your files. We recommend that you keep the application for a period of one year following the termination date
Ensure the Plan Member's pay-direct drug /certificate card is terminated as of effective date.
