Administrative services · Insurance Benefits ·



Download 5.08 Kb.
Date conversion26.11.2016
Size5.08 Kb.

ADMINISTRATIVE SERVICES

· Insurance Benefits ·



TERMINATING DENTAL INSURANCE

You may only terminate your dental insurance for one of the following reasons:

  • Open Enrollment-voluntary cancellation allowed (out for two years)

  • If your job assignment becomes less than 50%

  • Qualifying Event

  • Cancel a dependent if he/she has other dental coverage

Please terminate my Dental Insurance:


(Check one)
 For myself and any/all dependents
 Remove dependent (s) (list names) ___________________________________

___________________________________


___________________________________

Effective Date of Change: 1/1/2015

_____________________________ _______________________

Signature Date

_____________________________ _______________________



Print Name SSN # or Banner ID#


Cuesta College Insurance Benefits  PO Box 8106  San Luis Obispo, CA 93403-8106

Phone 805-546-3161  Fax 805-546-3906  Stephanie_vieira@cuesta.edu



The database is protected by copyright ©dentisty.org 2016
send message

    Main page