Gem State Developmental Center COBRA Termination

Note: This form is completed when there is a "Termination" of an Employee from your Employer Benefits Plans.

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Employer Information

Hire Date**

Termination Date**

Plan Type (Check all that apply)

Medical

Dental

Vision

Medical Plan Enrollment**

Medical Enrollment**

Dental Plan Enrollment**

Dental Enrollment**

Vision Plan Enrollment**

Vision Enrollment**

Form Attachments

Click on "Browse" to Attach Dental Form.

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Maximum file size 10MB (pdf, jpg or jpeg formats only)

Click on "Browse" to Attach Vision Form.

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Maximum file size 10MB (pdf, jpg or jpeg formats only)

Employee Information

First Name**

M.I.

Last Name**

Social Security Number**

Date of Birth**

Most Recent Mailing Address**

City**

Zip Code**

Additional Information

Employee Type of Qualifying Event**

Reduction in Hours

Involuntary Termination

Voluntary Termination

Dependent Qualifying Event**

Spouse/Dependent(s) Information

Note: When a spouse and/or dependent(s) are enrolled in the benefit plan(s), please be sure to provide their name and requested information when enrolled.

Remove Spouse?**

Yes

Spouse

First Name**

M.I.

Last Name**

Relationship**

Notes

Group Contact Email**

Signature of Group Contact Person**

Date of Signature

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Gem State Developmental Center COBRA Termination