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Small group termination form

1. Group name: *This question is required.

2. Group ID: *This question is required.

3. Renewal date: *This question is required.

4. Termination date: *This question is required.

5. Agent of record: *This question is required.

6. Group representative name: *This question is required.

7. Does the group have PriorityHRA? *This question is required.

8. Does the group have Optimized Level Funding (OLFO)? *This question is required.

9. Early Termination – The OLFO fee disclosure outlines the fees applicable to groups that choose to terminate prior to the end of the policy period. These fees include two months of aggregate claims funding, aggregate premium, and administrative charges. *This question is required.

I acknowledge the early termination fees and understand that additional charges may apply if the group ends coverage before the policy period concludes.

9. What is the primary reason the group is leaving Priority Health? *This question is required.

Please enter an 'other' value for this selection. * This question is required.

10. How is the group handling their health insurance? *This question is required.Select all that apply

Switched to a new group carrier
Switched to individual coverage
Switched to Medicare
Joined an association
Moved out of the service area
Company closed
No longer offers group health coverage
Switched to a private exchange
Other - Write In Please enter an 'other' value for this selection.

11. Which carrier did they choose? *This question is required.

11. Name of carrier *This question is required.

11. Which exchange did they choose? *This question is required.

11. Competitor % savings *This question is required.

11. Please provide the Association name *This question is required.

11. If circumstances change, would the group consider returning to Priority Health? *This question is required.

12. Any additional information you'd like to share?

13. Use your mouse, laptop touchpad or phone screen to sign below. *This question is required.Please remember to type your name below your signature.

Clear

Sign name using mouse or touch pad

Signature of

14. Please confirm your role. *This question is required.

Please enter an 'other' value for this selection. * This question is required.