Insurance Carrier Cancellation Form
This form should be used when an insurance carrier has canceled paid family and/or medical coverage with an entity. DFML will update their record to reflect the information reported by the insurance carrier. An acknowledgement is received once the form is submitted.
Employer Information
Do you have multiple entities under one policy?
If Yes, you must list each entity name and unique EIN.
Yes
No
Multiple Employer Information
How many entities do you want to add?
(Required)
Please enter a number from
1
to
15
.
Multiple - Entity 1
Entity 1 Name
(Required)
Entity 1 FEIN
(Required)
Multiple - Entity 2
Entity 2 Name
(Required)
Entity 2 FEIN
(Required)
Multiple - Entity 3
Entity 3 Name
(Required)
Entity 3 FEIN
(Required)
Multiple - Entity 4
Entity 4 Name
(Required)
Entity 4 FEIN
(Required)
Multiple - Entity 5
Entity 5 Name
(Required)
Entity 5 FEIN
(Required)
Multiple - Entity 6
Entity 6 Name
(Required)
Entity 6 FEIN
(Required)
Multiple - Entity 7
Entity 7 Name
(Required)
Entity 7 FEIN
(Required)
Multiple - Entity 8
Entity 8 Name
(Required)
Entity 8 FEIN
(Required)
Multiple - Entity 9
Entity 9 Name
(Required)
Entity 9 FEIN
(Required)
Multiple - Entity 10
Entity 10 Name
(Required)
Entity 10 FEIN
(Required)
Multiple - Entity 11
Entity 11 Name
(Required)
Entity 11 FEIN
(Required)
Multiple - Entity 12
Entity 12 Name
(Required)
Entity 12 FEIN
(Required)
Multiple - Entity 13
Entity 13 Name
(Required)
Entity 13 FEIN
(Required)
Multiple - Entity 14
Entity 14 Name
(Required)
Entity 14 FEIN
(Required)
Multiple - Entity 15
Entity 15 Name
(Required)
Entity 15 FEIN
(Required)
Single Entity
Entity Name
(Required)
Entity FEIN
(Required)
The nine digit Federal Employer Identification Number associated with the employer, without spaces or hyphens.
Insurance Carrier Information
Insurance Carrier
(Required)
Name
(Required)
First Name
Last Name
Insurance Carrier Contact Email
(Required)
Policy Information
Effective Date of Coverage
(Required)
MM slash DD slash YYYY
Policy Coverage
(Required)
Family and Medical
Family Only
Medical Only
Policy Form Number
(Required)
SERFF Number
(Required)
Coverage Cancellation Date
(Required)
MM slash DD slash YYYY
Reason for Cancellation
(Required)
Opting back into state PFML plan
Change in Insurance Carrier
Insurance policy cancellation for non-payment of premium
Reason not given
Other
If other, please explain
(Required)
Cancellation Notice
Please Note- Only one attachment may be uploaded. Multiple pages can be submitted, if they are uploaded as one attachment.
Drop files here or
Select files
Max. file size: 50 MB.
Attestation
Name
(Required)
First Name
Last Name
I hereby attest that this information is true, accurate and complete to the best of my knowledge.
(Required)
Yes