Retiree Tapered Life Insurance
Retiree Tapered Life Insurance
Request to Cancel Coverage Form
Name : ______________________________________________(Please print)
Address: _____________________________________________
City , State, Zip;________________________________________
Last 4 digits of your Social Security Number: ________________
Please initial each of the following:
__________I acknowledge that my election to cancel coverage is irrevocable.
__________ I request to cancel my Tapered Life Insurance
I understand that my decision to cancel this insurance coverage is irrevocable. Coverage cannot be reinstated at a later date. If you are attempting to place another policy, do not discontinue coverage until your replacement coverage is active.
Coverage will be discontinued on the first day of the month following receipt of your properly completed Request to Cancel Coverage Form. If you have questions on the completion of this form, please call 1-877-608-0044.
_____________________________________________ ____________
Signature Date
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