Oregon Request for Termination. Oregon Request for Termination 2026

1. Click ‘Get Form’ to open the Oregon Request for Termination in the editor.
2. In Section 1, enter the Group Number and Group Name clearly. Ensure all information is legible to avoid processing delays.
3. Move to Section 2, where you will provide Employee or Dependent Termination Information. Fill in each name, date of birth, reason for termination, and last date of coverage accurately.
4. For each individual being terminated, select the type of coverage to terminate (Medical or Dental) by checking the appropriate box.
5. In Section 3, an Authorized Group Contact must sign and date the form. This confirms that no premiums were paid after the requested termination date.
6. Once completed, use our platform to save your changes and either fax or mail the form to the address provided at the top.

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