Employee Termination Request

Please complete the form below to terminate an employee from coverage. Attach any supporting documents.

Be sure to offer COBRA/State Continuation coverage if applicable. You can find information and forms on TrustMineral.com; contact us if you don't have your login information. You can also refer to your state's website.

Our service team will be in touch.

Thank you,

Elite Benefits Service Team

service@elitebenefits.net

708-535-3006

We will not share your information with any third-party. Privacy Policy.

Employee Termination Request Form

HR/Admin Contact Person

HR/Admin Email

HR/Admin Phone

Company/Employer

Employee First Name

Employee Last Name

Benefits Termination Date MM/DD/YYYY

Voluntary or Involuntary Termination

Reason for Benefits Termination

Last Date of Coverage MM/DD/YYYY

Program(s) to Terminate - Be sure to Select all programs if more than one(To select multiple, hold Ctrl or Command)

Service Request Notes - Please provide additional notes if needed.

Upload Forms if Applicable Here

Be sure to offer COBRA/State Continuation coverage if applicable. You can find information and forms on TrustMineral.com or your states website.

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