EOLWD-DFML

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

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)

Policy Coverage(Required)

Family and Medical

Family Only

Medical Only

This field is hidden when viewing the form

Policy Form Number(Required)

This field is hidden when viewing the form

SERFF Number(Required)

Coverage Cancellation Date(Required)

Reason for Cancellation(Required)

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

Max. file size: 50 MB.

Attestation

Name(Required)

First Name Last Name