Cancel Coverage

We’re sorry to see you go! Your request will undergo a verification process after submission. We will contact you once your request has been processed.

"*" indicates required fields

Member Name*

First Last

Your Member ID or Certificate Number*

Last four digits of SSN*

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Which plan would you like to cancel?*

Member’s Plan

Dependent’s Plan

Why are you canceling your plan?*

Comments

This field is for validation purposes and should be left unchanged.