Employee Termination from invoice Form
YOUR COMPANY'S NAME
*
YOUR NAME (Authorizing Company Officer)
*
YOUR Phone Number
*
-
Area Code
Phone Number
YOUR Email Address
*
example@example.com
YOUR TITLE
*
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Your Agent's name:
*
Your Agent's Email Address (so they receive a copy of this and can follow up for you)
jdoe@voluntarypartners.com
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Select all Carriers that apply:
*
Assurity
SBMA (MEC) plan
5Star Life
Beam Dental/Vision/Life
Recuro Telehealth/EAP
Prosperity
Sedera Healthshare
Recuro Virtual Primary Care (Recuro Complete)
Other
Effective Date of Terminations (needs to be the first of the month)
*
-
Month
-
Day
Year
Date
How Many People are we terminating from the invoice?
*
1
2
3
4
5
6
7
8
9
10
#1 Name
*
#1's DOB
*
-
Month
-
Day
Year
Date
#1's SSN#
*
#2 Name
*
#2's DOB
*
-
Month
-
Day
Year
Date
#2's SSN
*
#3 Name
*
#3's DOB
*
-
Month
-
Day
Year
Date
#3's SSN#
*
#4 Name
*
#4's DOB
*
-
Month
-
Day
Year
Date
#4's SSN#
*
#5 Name
*
#5's DOB
*
-
Month
-
Day
Year
Date
#5's SSN#
*
#6 Name
*
#6's DOB
*
-
Month
-
Day
Year
Date
#6's SSN#
*
#7 Name
*
#7's DOB
*
-
Month
-
Day
Year
Date
#7's SSN
*
#8 Name
*
#8's DOB
*
-
Month
-
Day
Year
Date
#8's SSN#
*
#9 Name
*
#9's DOB
*
-
Month
-
Day
Year
Date
#9's SSN#
*
#10 Name
*
#10's DOB
*
-
Month
-
Day
Year
Date
#10's SSN#
*
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: