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Cancel Dependent Instructions
Please refer to the sample Medical Insurance Enrollment form.
- Action Box--check the box for Cancel Dependent and print the effective date.
- Carrier Box--Do not check the Cancel box for Health Net or Blue Cross. Doing so might result in Termination of the coverage of the main enrollee, when all you wanted was to cancel one dependent.
- Personal Information--First and Last Name are necessary. You need not enter the address, unless there's been an address change.
- Social Security Number--Required for the main enrollee! Our database as well as those of all our insurance carriers are keyed on the SSN.
- Department, title, start date information--Not necessary on a Cancel Dependent form.
- Dependent Information--Show all covered dependents. In the Start date box, write "Cancel" or "Continue" for each dependent. Dependents not shown are apt to be cancelled by the carrier. Be very clear about who is continuing and who is being cancelled. Write a note if it can help clarify the situation.
- Signature of the Main Enrollee--Required. The main enrollee must sign and date a Cancel Dependent form or it can't be processed.
- Accounting Information for Postdoctoral Scholars--Not necessary on a Cancel Dependent form.
- Chair, Program Director, MSO or P.I. Signature--Required on a Cancel Dependent form.
- Contact Person Name--Since your responsibility as Department Contact person is to keep track of all insurance enrollments, charges, changes, and terminations for your enrollees, we will not process any insurance action that you don't know about. Please sign the form.
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Distribution--send the original, signed copy to the Human
Resources Office. Retain a copy for the Department file and provide a copy
to the member.