Request to Discontinue MEC Health Insurance Plan

Elections for group health insurance are irrevocable for the plan year under Section 125 plans. However, the Internal Revenue Service (IRS) provides specific instances when an employee can make midyear election. Employees must have one of the following "Qualifying Events" to cancel insurance outside of the open enrollment period.

Please place a checkmark next to the reason for cancellation. Check all that apply. *

Change in marital status.

Change in number of dependents or change in dependent status.

Change in employment status (reduction in average hours under 30).

Change in residence.

Change in spousal coverage.

Entitlement to Medicare or Medicaid.

Coverage needed is not offered.

Note that in order to cancel insurance outside of the open enrollment period, employees must qualify for one of the events above.

List the specifics about the qualifying event. *

Employee First Name *

Employee Last Name *

Employee Email Address *

Employee Telephony ID Number *

Cancellation Signature *

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