Health and Dental: Termination Form

Doctors of BC Health & Dental Plan

Termination of coverage
Please use this form to request termination of your Doctors of BC Health & Dental coverage. Please select the type of termination from the options below.
Type of Termination:
1. Sponsoring Physician/Employer
What is your name?
Your Email Address

Confirmation EmailReceives copy of termination request & used for DocuSign (if applicable). Please enter email address twice, for accuracy. Addresses must match.
Name of Sponsoring Physician or Clinic
Business ID, if known
your Business ID is found in the top right of your health and dental invoice
Are you the Sponsoring Physician of this plan?
Only the Sponsoring Physician or the Designated Authorized Person may complete this form.
If Designated Authorized Person, what is your title?
2. Withdrawal from Program
All terminations will take place as of the first of the month following receipt of this termination request. Note that premiums must be paid up to effective date of withdrawal.
We no longer wish to participate in the Doctors of BC Health & Dental Plan for the following reason(s):
Alternate coverage
Other reason
2. Termination of Employee Coverage (not including Parental Leave)
All terminations will take place as of the first of the month following receipt of this termination request. Note that premiums must be paid up to effective date of withdrawal.

Benefits should cease upon termination of employment. Any extension of coverage due to severance arrangements beyond the statutory limit is subject to approval by the Insurer. Please contact the Plan Administrator (Doctors of BC) in this event.
How many employees are you terminating coverage for?
Employee #1 Name:

First NameLast Name
Employee #1 Last Day Worked:

MonthDayYear
Date
Employee #1 Reason for Termination:
Employee #2 Name:

First NameLast Name
Employee #2 Last Day Worked:

MonthDayYear
Date
Employee #2 Reason for Termination:
Employee #3 Name:

First NameLast Name
Employee #3 Last Day Worked:

MonthDayYear
Date
Employee #3 Reason for Termination:
Employee #4 Name:

First NameLast Name
Employee #4 Last Day Worked:

MonthDayYear
Date
Employee #4 Reason for Termination:
Employee #5 Name:

First NameLast Name
Employee #5 Last Day Worked:

MonthDayYear
Date
Employee #5 Reason for Termination:
3. Parental Leave Termination
All terminations will take place as of the first of the month following receipt of this termination request. Note that premiums must be paid up to effective date of withdrawal.
Is the employee responsible for paying a portion of the benefit premiums?
NOTE: If the employer is paying 100% of the cost of benefits, all benefits continue for the duration of the parental leave.

Under the Employment Standards Act, if any employee is on leave their employment is considered continuous. Therefore, you must continue to make payments to any benefit plans unless the employee chooses not to continue with his/her share of the cost of a plan, or the employee has voluntarily terminated his/her employment. We strongly advise that you ensure you are in compliance with this regulation.
Parental Leave Employee Name:

First NameLast Name
Parental Leave Employee Email Address

Confirmation Emailplease enter twice, for accuracy. Entries must match. For DocuSign purposes
Parental Leave Employee Last Day Worked:

MonthDayYear
Date
Please note: if an employee terminates coverage as a result of parental leave, they will need to complete evidence of insurability to re-join the plan.

Next Steps: We will send this termination request to you and your employee via DocuSign to obtain their signoff.
4. Sponsoring Physician/Employer Signature
I request the above terminations to be processed. I understand that benefits will cease on the first of the month following receipt of this form.
Authorized Signature
Date

MonthDayYear
Date
Should be Empty:

Doctors of BC Health & Dental Plan

1. Sponsoring Physician/Employer

2. Withdrawal from Program

2. Termination of Employee Coverage (not including Parental Leave)

3. Parental Leave Termination

4. Sponsoring Physician/Employer Signature