Personal Life Insurance Cancellation Form

The Personal Life Insurance Cancellation form must be completed by the employer when an employee separates from employment with the church or organization. This form will initiate communication to the employee (insured) to establish direct billing with Transamerica.

If an employee (the insured) is voluntarily electing to cancel coverage, the employee must complete the form and notify the church administrator.

Section 1: Employer & Employee Information

Employer Account Number(Required)

Church/Organization Name(Required)

Employee Name(Required)

First Last

Employee Email(Required)

Enter Email Confirm Email

Employee Phone(Required)

Cancellation Reason:(Required)

Employee is no longer employed with my church/organization

Employee is voluntarily cancelling their Personal Life Insurance coverage (still employed)

Employment Details and Administration Approval

Last Day of Employment(Required)

MM slash DD slash YYYY

Administrator Name(Required)

First Last

Administrator Email(Required)

Enter Email Confirm Email

Administrator Signature(Required)

Date Signed(Required)

MM slash DD slash YYYY

Employee Cancellation Details and Employee Authorization

Requested Termination Date(Required)

MM slash DD slash YYYY

Reason for Cancellation (optional):

Premiums are too expensive

Change in financial situation/budget restraints

Met with a financial planner and determined I did not need this coverage

Employee Signature(Required)

Date Signed(Required)

MM slash DD slash YYYY

Administrator Name(Required)

First Last

Administrator Email(Required)

Enter Email Confirm Email