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Forma Cancelación/Reembolso

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ACA MARKETPLACE INSURANCE COVERAGE

NOTICE OF INSURANCE CANCELLATION AND PREMIUM REFUND (if applicable)

Date: ______________________________________________________________

Cancellation Effective Date

To: ____________________________________________________________________

Name of Insurance Company

From: __________________________________________________________________

Name of Insured and Coverage ID Number

Re: ACA Insurance Marketplace Coverage Cancellation Notification

     Premium Refund (if applicable)

To Whom It May Concern:

This letter is to inform you that I have obtained health insurance coverage with another carrier for 2015, as permitted under the ACA law. Insurance coverage with your Company should expire on the above cited Cancellation Effective Date. This letter serves as our absolute request that you stop any and all bank drafts to pay for our health insurance from our bank account for any premiums for 2015 coverage. In the event any premium has been deducted from our bank account for 2015 coverage, proceed to issue a refund immediately. Failure on your part to diligently return the money owed to us will result in a complaint against you with the U. S. Department of Health and Human Services to secure our lawful premium refund.

Sincerely,

__________________________________________________

Signature of Insured

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