Wea termination Notification Form For use before

Дата канвертавання27.04.2016
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WEA Termination Notification Form

(For use before your billing is returned to Premera)

Please help us by updating your terminating employees’ records in a timely fashion. Complete this form by checking all products being dropped, based on the following:

Send the completed form to your WEA/APA Billing Representative by e-mail or fax to 425-918-5204.

Group Name


Group Contact


Group Number




Effective Term Date


Subscriber Name


All Coverage

If not, specify which ones must remain ACTIVE
(i.e., Dues, Voluntary Disability, AD&D, LTC)




















Is a subscriber being terminated due to his/her death? If yes, who?      

022093 (06-2013)

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

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