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Get DC Center For Nonprofit Advancement Combined Termination Form 2009-2024

Has voluntarily chosen to drop the insurance coverage indicated. Do not send COBRA information. Terminate all insurance coverage for the following employee and covered dependents, and send COBRA information, if applicable. Terminate coverage for the following person(s) ONLY: SSN: Employee Name: Employee/Dependent Home Address: Coverage to be terminated (Check all that apply) Single Family Employee/ Child Employee/ Spouse UnitedHealthcare PPO UnitedHealthcare Choice Plus.

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