Diane Barber

Capital Region Benefits
3819 Market Street
Camp Hill, PA 17011
Phone: (717) 975-9300
Fax: (717) 975-9303

VBA Deletions and Terminations

* - Denotes a required field

Complete the form below to request that an employee be removed from VBA coverage

*Group name
*Client ID Number (please refer to invoice)
*Employee Name
*Employee SSN
*Name of individuals to be deleted/terminated
*DOB of individuals to be deleted/terminated
*Zip Code of person to be deleted/terminated
*Relationship (to employee) of person to be deleted
*Effective date of termination (MM/DD/YYYY)
(Employees/dependents terminated on the last day of the month - you may terminate employees/dependents up to 60 days prior to today's date)
*Reason for termination
*Name of person authorizing termination
(By typing your name you are certifying that you have authority to administer these benefits, your name will act as an electronic signature)
*Phone number at which you can be reached
*E-mail address of person authorizing termination
(A confirmation e-mail will be sent at your attention)
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