Professional Benefit Administrators
1130 Hurricane Shoals Road NE, Suite 2300 ~ Lawrenceville , GA   30043
Phone:  770-963-3939 or 800-578-2082 ~ Fax:  770-963-6126 or 888-264-6975

Please cancel the allotment payments for Members Name: 

Member SSN:  , effective .  Please hold all incoming monies (if any) in escrow until they cease,  upon ceasing please issue a refund  check.

Thanks!

Signature:  ________________________________________________

Comments:  ____________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________