VCPFA Retiree/Management Benefits Cancellation Request
Name
*
First Name
MI
Last Name
I am
*
a VCPFA Retiree
spouse/dependent of a VCPFA Retiree
Date of Retirement (VCPFA Retirees)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
No Medical plan - Dental/Vision Only
I do not have a VCPFA Medical plan - I only have VCPFA Dental and/or Vision
I have a VCPFA Medical Plan
I have both VCPFA Medical and dental and/or vision
Other
Please cancel coverage as of
*
Retirement Date
Promotion Date
Upcoming Plan Year (for open enrollment changes only)
Other
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Which Benefits do you wish to cancel? (Check all that apply)
Medical
Dental
Vision
Cancel the following from my VCPFA Medical plan
*
Self only - Leave qualifying dependents (if any) enrolled
All members enrolled
Dependents (list below)
Other
Cancel the following dependents:
Include Name, Relationship, DOB
I am canceling for the following reason:
*
I/we are covered by another employer sponsored Group Health Plan.
I have promoted and am no longer eligible for VCPFA Medical
I/we have obtained other insurance coverage (not a group plan).
Medicare Eligibility
I/we are covered by another employer sponsored Group Health Plan. I understand that I may be asked to provide PROOF OF GROUP HEALTH COVERAGE annually, or it may be requested if I wish to re-enroll in a VCPFA Medical plan at a later date.
Initial
I/we have obtained other insurance coverage (not a group plan). I understand myself and my dependents will no longer be eligible for medical insurance through the VCPFA insurance plans.
Initial
Medicare Eligibility
Cancel my VCPFA Medical Insurance for myself, I have reached Medicare Eligibility. Please continue coverage for my spouse and any eligible dependents until I notify the Association that they are no longer eligible to continue on the plan (Spouse reaches Medicare Eligibility, Dependents no longer qualifies for coverage under the plan, maximum age).
Cancel my VCPFA Medical Insurance for my spouse, they have reached Medicare Eligibility. Please continue coverage for me and any eligible dependents until I notify the Association that I am no longer eligible to continue on the plan.
Cancel VCPFA Medical Insurance for my spouse and eligible dependents. Spouse has met medicare eligibility, therefore, dependents no longer qualify for coverage. Dependents will be offered COBRA.
Regarding your VCPFA Health benefits
Plan eligibility
I have read and fully understand the contents of this form. I agree to the terms and conditions stated above.
Initial
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VCPFA Dental Status
*
I am enrolled in VCPFA Dental
I am not enrolled in VCPFA Dental
VCPFA Dental
I wish to keep my VCPFA Dental
I wish to change/cancel VCPFA Dental
Cancel the following from my VCPFA Dental Plan
Self only - Leave qualifying dependents enrolled
All members enrolled
Dependents (list below)
Cancel the following dependents:
Include Name, Relationship, DOB
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VCPFA Vision status
*
I am enrolled in VCPFA Vision
I am not enrolled in VCPFA Vision
VCPFA Vision
I wish to keep my VCPFA Vision
I wish to change/cancel VCPFA Vision
Cancel the following from my VCPFA VisionPlan
Self only - Leave qualifying dependents enrolled
All members enrolled
Dependents (list below)
Cancel the following dependents:
Include Name, Relationship, DOB
Supporting Document Upload
Browse Files
Use this to send proof of other coverage or other supporting documents requested by VCPFA
Cancel
of
Submit
Should be Empty: