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.

Member Name*
First Last
Your Member ID or Certificate Number*
Last four digits of SSN*
Date of Birth*
MM slash DD slash YYYY
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?*
- No longer need coverage
- Found other insurance
- Too expensive
- Older than 80 years old
- Prefer not to answer
- Other
Comments
Comments
This field is for validation purposes and should be left unchanged.