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)

Employee Name *

Employee Email Address

Street Address *

City *

State *

Zip Code *

Employer (Church/District) Name *

Church code

Last Day of Active Employment (if ending employment, please list the actual last day of active employment for Life/LTD conversion purposes) * +

Last Day of Coverage * +

Reason for leaving the plan

Additional Notes

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

I understand that the employee is covered for the remainder of the last active month of employment under regular coverage.

I understand that if a church voluntarily leaves the plan (except for loss of Pastor) there is a 12 month waiting period before enrolling in the health plan again.

I agree to pass along a copy of this document to the concluding employee so they are aware of their coverage extension options.

Printed name of authorized employer representative *

Title *

Email *

Contact Phone *

Authorized Employer's Signature *

clear

Signature Date * +