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Discovery benefits cobra benefits termination form 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the Primary Participant Information section. Enter your full name, Social Security Number, and the name of your employer sponsoring the benefits. Ensure that all required fields marked with an asterisk are completed.
- In the Benefit Termination Information section, list the names of individuals affected by the termination and their final date of coverage. Specify which benefits you wish to terminate, checking the appropriate boxes for Medical, Dental, and Vision coverage.
- If applicable, detail any Other Benefits you wish to terminate. Be thorough; incomplete information may result in all benefits being terminated.
- Finally, complete the Primary Participant Certification by signing and dating the form. If terminating a spouse's coverage, ensure they also sign and date where indicated.
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wex cobra termination form
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