Disenrollment Portal

Please be advised this form is only to be completed by those authorized to make changes to employee benefits!

Company Name

Name of person completing this form

First Name

Last Name

Email address of person completing this form

Employee's Name

First Name

Last Name

Employee Date of birth

YYYY

Last day worked

YYYY

Reason for request

Effective date of change on the first day of:

CORA eligible?

Yes

Employee's Personal Email

Please provide email address if COBRA eligible

Advisory Services

Portalis is here to help business owners and individuals with reviews of their current coverages. We will review existing Medicare plans, health plans, life insurance policies, long term care policies, disability policies, annuity plans to ensure you have adequate coverage.