Wea termination Notification Form For use before




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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

     

Phone

     

Effective Term Date

     




Subscriber Name

Term

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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