This form is to be completed by an authorized employer representative of the Church/District.

Important Information

  • Complete this form only if an employee is ending active health plan coverage.
  • Please notify Alliance Benefits immediately once an employee has ended active employment.
  • Coverage will end on the 1st day of the month following the last day of active employment coverage.
  • Employee may be eligible for Coverage Extension the first of the month once employment ends (being a church group plan, we are unable to offer COBRA).
  • Coverage Extension is the same coverage the employee had for active coverage, minus Life Insurance and Long-Term Disability, if applicable. The months of coverage offered will coincide with the number of months employed up to 12 months or until other coverage becomes available.
  • Life Insurance and Long-Term Disability coverages will end on the last day of month in which employment ends. It may NOT be extended during a severance period. Conversion offers will be offered once employment ends.

Employee Information (necessary for coverage extension offer)

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Authorized Signature (to be completed by authorized person for the Church/District)

Authorized Employer's Signature *
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