Notice Of Termination Of Coverage

Avalon Benefit Services, Please terminate coverage for the following employee:

Employee Name:
Employee SSN:
Effective Date of Termination:   
Group Number:
Name of Plan:
Date:      Signature:

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6543 Commerce Parkway, Suite M, Dublin, OH 43017
Phone: 800-310-6645    Fax: 844-328-5824