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Click ‘Get Form’ to open the blue cross blue shield cancellation form in the editor.
Begin by entering the Group Name and Group Number at the top of the form. This information is essential for identifying your coverage.
Fill in your personal details, including your Member Number, Last Name, First Name, MI (Middle Initial), and Telephone number.
Specify the Cancellation Effective Date, which is crucial as it determines when your coverage will end.
Indicate whether you are canceling employee coverage by selecting 'YES' or 'NO'. If you select 'YES', be aware that this will also cancel coverage for all dependents.
If applicable, provide a reason for cancellation and complete any additional fields regarding dependents if you chose not to cancel them all.
Finally, ensure to sign and date the form where indicated. Your signature is required for dependent cancellations.

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