Please fill out the form below and click the submit button.
Employer Name *
Employee First Name *
Employee Middle Name
Employee Last Name *
Employee SS# *
Employee Date of Birth *
Employee Gender MaleFemale
Employee Hire Date
Employee Mailing Address
City
State
ZIP
Termination / Qualifying Event Date *
Termination Type
VoluntaryInvoluntary
Qualifying Event Type *
Employee TerminationEmployee Reduction in Hours
Dependent Name
Dependent Date of Birth
Dependent SS#
Relationship to Employee
Dependent Qualifying Event Type
Death of EmployeeLoss of Dependent StatusEmployee Entitlement to MedicareDivorce/Legal Separation
FSA Plans to Remove
Medical FSADependent Care FSA
Health Plans to Remove
HRA PlanMedical CoverageDental CoverageVision Coverage
HRA Plan Tier
Medical Coverage Tier
Dental Coverage Tier
Vision Coverage Tier
Name of Person Completing Form *
Job Title *
Email Address *
Date Form Completed *
E Benefits Administration © copyright 2017 | Privacy Policy | Terms & Conditions
