Terminate Employee Benefits Form

Complete this form to terminate employee benefits. You may also print this application and fax to (415) 512-1115. Please call (415) 512-2100 if you have any questions. Thank you.

	* Required.
Employer *
Employee Name *	(First, last name)
Employee Termination Date *	(MM/DD/YYYY)
Last Day of Coverage *	(MM/DD/YYYY)
Street Address to send COBRA Notice *	(Home address of the employee)
City
State / Zip *	/
Coverages to be terminated:	Medical
	Dental
	Vision
	Short Term Disability
	Long Term Disability
	Long Term Care
	Life
	How many children?

If you do not receive a written confirmation that we have received this request, please resend or call immediately. Sweet and Baker will not be responsible to process your employee termination until you have written confirmation from us. Thank you.