Get Termination Request Form - Coventryone

Filling out the Termination Request Form - CoventryOne is a straightforward process that allows users to request the cancellation of their insurance coverage. This guide will provide clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out your termination request form.

1. Click ‘Get Form’ button to access the termination request form and open it in your preferred document editor.
2. Begin by filling in the 'Member Name' field with your full name as it appears on your policy.
3. Next, provide your 'Member Address', ensuring it is the address associated with your insurance account.
4. Enter your 'Identification Number', which can be found on your insurance card or policy documents.
5. Include your 'Member’s Phone number' so that CoventryOne can contact you if necessary.
6. Specify the 'Requested Cancellation Date', which is the date you wish your coverage to end.
7. Select the appropriate option under 'Subscriber’s Termination Request', choosing either 'Entire Policy', 'Subscriber only', or 'Dependent(s) Only'. If selecting dependents, list their details in the space provided.
8. Indicate the reason for termination by checking the corresponding box. Choose from options such as 'Premium Rate', 'Service provided by Coventry', or 'Moving out of Coverage Area', among others.
9. If applicable, explain any other reasons in the space provided to ensure full clarity.
10. Sign and date the form. Ensure all dependents aged 18 and over also include their signatures.
11. Once completed, review the form for accuracy, then save your changes. You may choose to download, print, or share the form as needed.

Complete your termination request form online today to ensure timely processing of your request.