VIP Change / Termination Request
Complete this request for a change or termination of coverage with any VIP carrier. Provide the employee and employer details that apply, then complete the change or termination section and sign the acknowledgment.
Which carrier(s) is this request for? (Mark All that apply)
*
Assurity
Ameritas
Beam
Five Star Life
Recuro
Lyric
Boston Mutual
Other
Other carrier name
Assurity Details
Complete the Assurity questions below. Pick a Request type to see the Assurity change or termination fields.
Requestor & Employee Information
Who’s completing this?
*
Employee
Employer-HR
Request type
*
Change
Termination
Employer/ Company/Group name
*
Employee first name
*
Employee last name
*
Employee date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee last 4 digits of SSN
*
Employee phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee email
*
example@example.com
Employer contact name
Employer contact title
Employer contact email
example@example.com
Change Request Details
What is changing
*
Add coverage
Drop coverage
Add dependent
Remove dependent
Address/Name
Beneficiary
Other
Which Assurity coverages
Accident
Critical Illness
Hospital
Disability/STD
Life
Details of the change
Change reason
*
Marriage
Birth/adoption
Divorce
Loss of other coverage
Open enrollment
Other
Requested effective date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dependent 1 name
Dependent 1 relationship
Please Select
Spouse
Child
Domestic Partner
Other
Dependent 1 date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dependent 1 gender
Female
Male
Dependent 2 name
Dependent 2 relationship
Please Select
Spouse
Child
Other
Dependent 2 date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dependent 2 gender
Female
Male
Dependent 3 name
Dependent 3 relationship
Please Select
Spouse
Child
Other
Dependent 3 date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dependent 3 gender
Female
Male
Termination Request Details
Coverages Ending
*
All
Accident
Critical Illness
Hospital
Disability/STD
Life
Reason
*
Left Employment
Voluntary Drop
Death
Other
Last Day Worked or Coverage End Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Ameritas Details
Ameritas group number
Ameritas coverages
Dental
Vision
Hearing
Ameritas dependents affected
Ameritas effective/end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Beam Details
Beam group number
Beam coverages
Dental
Vision
Life
Beam end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Five Star Life Details
Five Star Life policy/group number
Five Star Life coverage
Five Star Life end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Recuro Details
Recuro plan/group
Recuro members affected
Recuro end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Recuro terminations must be received by the last day of the month.
Lyric Details
Lyric plan
Virtual Primary Care
Virtual Urgent Care
Lyric members affected
Lyric end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Boston Mutual Details
Boston Mutual coverage
Basic Life
Voluntary Term Life
Spouse coverage
Spouse date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Boston Mutual end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Carrier Details
Other carrier coverage description
Other carrier end date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Beneficiary name
Beneficiary relationship
Beneficiary percentage
Signature & Acknowledgment
Signature
*
Date signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Acknowledgment
*
I acknowledge that the information provided is accurate and complete.
Submit
Submit
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