Premium Billing Refund Request Form

For active participants: a specific refund amount is required

For terminated participants: refund will be processed for any unallocated funds. COBRA refunds are limited to 30 days for retroactive terminations.

Refunds are processed within 15 business days of form submission.

Employee Information

Name*

First Name

Last Name

Email*

Employer (or former employer)*

Last 4 of SSN*

Member ID (located on payment coupons or within member portal)

Requested Refund Amount

Signature

Signature *

I hereby request a refund for any unused premiums or premiums specified above. I acknowledge that my coverage will end on the termination date indicated on my account. I certify that I am the account holder and have the authority to make this request.

Name*

First Name

Last Name

Date*