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Comprehensive submission instructions are provided, including contact information for Planned Administrators Inc. (PAI). This template is designed to streamline administrative processes for managing benefits and ensuring accurate record-keeping for underwritten plans, including Medical, Dental, Vision, Life, and Disability coverage.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/termination-involuntary-loss-of-coverage-form/285226/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/termination-involuntary-loss-of-coverage-form/285226.png","ImageObject",442,249,{"name":42,"@type":43},"Alex Sinclair","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-02","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",6,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who is responsible for completing this form?","Question",{"text":63,"@type":64},"The company representative is responsible for completing Sections 1, 2, 3, and signing and dating Section 4 of the form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What is the deadline for submitting the form to PAI?",{"text":68,"@type":64},"Completed forms must be submitted to PAI within five days of the employee's termination.",{"name":70,"@type":61,"acceptedAnswer":71},"What should be listed in Section 3?",{"text":72,"@type":64},"Section 3 should contain the names of all family members whose coverage needs to be cancelled, along with their addresses if they do not reside with the employee.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},285226,1790464829,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},1099523882182,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Termination/Involuntary Loss of Coverage  \nMail or fax this form to:  \nPAI, P.O. Box 6702, Columbia, SC 29260-6702  \nFax (803) 870-8060  \nWhen Terminating All Benefits:  \nCompany Representative must:  \n• Complete Sections 1, 2, 3 and sign and date Section 4.  \n• Submit completed form to PAI within five days of employee termination.  \nQuestions? Call Customer Service (866) 740-4006.  \nSection 1.  \nEmployee’s Name:   SSN:   Last First Middle  \nAddress:    \nStreet City State ZIP  \nGroup Number:   Effective Date of Termination:    \n(The effective date of termination is the last day of the pay period for which premiums were deducted.)  \nSection 2. Reason for Termination (Check one and enter the date requested.)  \n Termination of Employment  Death of Employee  Reduction of hours  \nLast Day Worked:   Date of Death:   Last Day Worked:    \n Loss of Dependent Coverage  Divorce/Legal Separation  \nDate of Coverage Loss:   Date of Divorce/Separation:    \nSection 3. List all family members to be cancelled. (Also add dependent address if not residing with employee.)  \nDependent Names (First and Last) Address (if not residing with employee)  \n\n| Name | Street | City | State | ZIP |\n| --- | --- | --- | --- | --- |\n| Name | Street | City | State | ZIP |\n| Name | Street | City | State | ZIP |\n\nName Street City State ZIP  \nSection 4.  \nAuthorized Company Representative Signature:   Date:    \nPlease Print Name:   Telephone:    \n(Please include area code.)  \nSection 5.  \nEmployee Signature (if available):   Date:    \nThe Medical/Rx, Dental and Vision plans are underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois.  \nThe Term Life/Accidental Death, and ShortTerm Disability plans are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois.  \nEsential StaffCARE plans administered by Planned Administrators Inc., P.O. Box 6702 Columbia, South Carolina 29260  \nRev 10-26-2020","cbCaijITK6yR4XPJ","https://ap.wps.com/l/cbCaijITK6yR4XPJ","pdf",187552,"English","# Section 1: Employee Information\n## Group and Termination Details\n# Section 2: Reason for Termination\n# Section 3: Dependent Cancellation List\n# Section 4: Authorized Representative Signature\n# Section 5: Employee Acknowledgment","[{\"question\":\"Who is responsible for completing this form?\",\"answer\":\"The company representative is responsible for completing Sections 1, 2, 3, and signing and dating Section 4 of the form.\"},{\"question\":\"What is the deadline for submitting the form to PAI?\",\"answer\":\"Completed forms must be submitted to PAI within five days of the employee's termination.\"},{\"question\":\"What should be listed in Section 3?\",\"answer\":\"Section 3 should contain the names of all family members whose coverage needs to be cancelled, along with their addresses if they do not reside with the employee.\"}]","Termination-Involuntary Loss of Coverage Form | PDF",1789629690]