Form to End Active Coverage

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.
Coverage will end on the 1st day of the month following the last day of active employment coverage.
Once an employee has ended active employment, the Alliance Benefits Office must be notified immediately.
The first of the month after active employment ends, the employee may be eligible for coverage extension (because we are a church group
plan, we are unable to offer COBRA but offer something similar called Coverage Extension).
Coverage Extension is the same coverage the employee had for active coverage, minus the Life Insurance and Long Term Disability, if applicable. Alliance Benefits will offer the number of months that they were on active coverage up to a maximum of 12 months or until they become eligible for other coverage, whichever comes first.
Life Insurance coverage and Long Term Disability coverage will end on the last day of the month in which employment ends and may NOT be extended during a severance period. We may be able to offer conversion if we are promptly informed. Please contact the Alliance Benefits Office for details.

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 * +