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Cobra benefits termination form

Cobra termination form 2026

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The COBRA Benefits Termination Form is used to request the termination of one or more benefits under COBRA. It requires notification to Discovery Benefits at least 15 days before the desired termination date to ensure proper processing. Refunds for overpayments are issued only if they exceed $25. The form collects information about the primary beneficiary, specifies which benefits are being terminated, and includes a certification section for signatures.

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Click ‘Get Form’ to open the COBRA Benefits Termination Form in the editor.
Begin by filling out the Primary Qualified Beneficiary Information. Enter your full name, Social Security Number, and previous employer's name without abbreviations. Provide a day telephone number and an email address for communication.
In the Benefit Termination Information section, specify which benefits you wish to discontinue (Medical, Dental, Vision, etc.). Indicate the effective date of termination using the format mm/dd/yyyy and list all affected individuals.
Complete the Primary Qualified Beneficiary Certification by signing and dating where indicated. If terminating coverage for a spouse, ensure their signature is also included.

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wex cobra benefits termination form

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