Health Insurance Dependent Removal Request Form
Use this form to request removal of a dependent from a health insurance plan. Please provide the requested details so the removal can be processed.
Request Details
Requester Full Name
*
First Name
Middle Name
Last Name
Relationship to the Plan
*
Please Select
Employee
Spouse
Domestic Partner
Dependent
Guardian
Other
Employee or Policy Number
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email Address
*
example@example.com
Dependent Removal Information
Dependent Full Name
*
First Name
Middle Name
Last Name
Relationship to Subscriber
*
Please Select
Spouse
Child
Stepchild
Domestic Partner
Other
Requested Removal Effective Date
*
-
Month
-
Day
Year
Date
Reason for Removal
*
No longer eligible
Coverage change
Divorce/Separation
Dependent aged out
Deceased
Other
Supporting Details and Certification
Additional Comments or Circumstances
Attestation
*
I confirm the information provided is accurate to the best of my knowledge and I understand this removal request may affect coverage.
Submit Request
Should be Empty: