Employee Insurance Cancelation
"
*
" indicates required fields
Client Name:
*
Employee Name:
*
SSN#:
*
DOB:
*
I wish to cancel the following insurance:
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Medical
Dental
Vision
Life
Short Term Disability
Long Term Disability
Cancer
I am canceling for the following reason:
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Cost
Spouse Coverage
Not Needed
Other
I am canceling for the following reason - Other
Consent
*
I am notifying my employer as well as iAS that i would like to cancel the above insurance as of today.
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Signature
*
Print
*
Date
*
MM slash DD slash YYYY
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Name
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First
Last
Email
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Phone
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Company Name
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Product Interested In
(Required)
Product Interested In
Payroll
Human Resources
PEO Options
Benefits & Insurance
Time & Attendance
Reporting
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Email
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