José González App #2021-0302

505-505-5050 email@juno.com

Assigned To: Trinity Angelino

Pending Review Under Review Reviewed & Approved Change Request Editing: Locked

Cancel Coverage

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Cancel Coverage

Note: Monthly deduction will continue unless written notification to cancel is made one month in advance. Effective date of cancellation is not retroactive.

I Would Like To Cancel Coverage For Jane Doe (Retiree) John Doe (Spouse) John Doe (Domestic Partner) Jannie Doe (Dependent 1)

Jane Doe (Retiree)

Cancel Medical Plan Cancel Dental Plan Cancel Vision Plan Cancel Supplemental Life Plan

Effective Date

John Doe (Spouse)

Cancel Medical Plan Cancel Dental Plan Cancel Vision Plan Cancel Supplemental Life Plan

Effective Date

John Doe (Domestic Partner)

Cancel Medical Plan Cancel Dental Plan Cancel Vision Plan Cancel Supplemental Life Plan

Effective Date

Jannie Doe (Dependent 1)

Cancel Medical Plan Cancel Dental Plan Cancel Vision Plan Cancel Supplemental Life Plan

Effective Date

Declaration and Signature

I authorize the changes above

Today's Date

Discard Changes and Exit Submit Changes and Exit

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