VBA Deletions and Termination

* - Denotes a required field
Complete the form below to request that an employee be removed from VBA coverage

Group Name*

Client ID Number (please refer to invoice)*

Employee Name*

Employee SSN*

Name of Individuals to be deleted/terminated*

DOB of individuals to be deleted/terminated*

Zip Code of person to be deleted/terminated*

Relationship (to employee) of person to be deleted*

Effective date of termination(MM/DD/YYYY)*

Employees/dependents terminated on the last day of the month-you may terminate employees/dependents up to 60 days prior to today's date

Reason for termination*

Name of person authorizing termination*

By typing your name your are certifying that you have authority to administer these benefits, your name will act as an electronic signature

Phone number at which you can be reached*

E-mail address of person authorizing termination*

A confirmation e-mail will be sent at your attention

In an effort to prevent spam, please select the response