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Address Date:

To,

Company Name,

RE: Cancellation of Insurance Plan #

This is to inform you that I am getting enrolled into a group health and dental plan from my employer
and I would like to stop my individual Insurance plan as of date. Please take this letter as a formal
request to cancel my health insurance plan # --------- ID # 000000000 and stop all charges for premium
payments. Please make this cancellation effective as of date. I also request written confirmation of this
cancellation, along with a refund for unused premiums.

Thanks and Regards,

Your Name