"Change in Status/Termination Election Form - Section 125 Cafeteria Plan"

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Section 125 Cafeteria Plan
Change in Status/Termination Election Form
Complete this form when a change in status has occurred which affects your Cafeteria Plan election. All changes must be due to
and consistent with the change in status.
Company name ____________________________________________
Employee name ___________________________________________
Social Security Number ___________________________________
Phone _________________________________________
Employee address __________________________________________________________________________________________
Effective date of change ____________________________
If terminating, date of last deduction _______________________
As a participant in the Cafeteria Plan, I am entitled to revoke my prior benefits election and enter into a new election in the event of certain
changes in status. I understand that the change in my benefits election must be due to and consistent with the change in status and that the
change must be acceptable under the Regulations issued by the Department of Treasury.
I certify that I have incurred the following change in status:
Change in Marital Status
£ £ Change in legal marital status including marriage, death of the spouse, divorce, legal separation or annulment.
Change in Number of Tax Dependents
£ £ Change in the number of tax dependents including birth, adoption, placement for adoption or death of a dependent.
Changes in Spouse or Dependent’s Eligibility Under an Employer’s Plan
£ £ Change in dependent status in satisfying or ceasing to satisfy the eligibility requirements of the plan, such as
attainment of limiting age or student status or change in marital status.
£ £ Judgment, decree or order including the imposition of a Qualified Medical Child Support Order.
£ £ Gain or loss of Medicaid or Medicare entitlement.
£ £ Entitlement to COBRA.
£ £ Special requirements relating to the Family and Medical Leave Act (FMLA).
Change in Employment Status that Changes Eligibility Status
£ £ Change of employment status, such as termination or commencement of employment by the employee, spouse or dependent.
£ £ Change in work schedule, such as a reduction or increase in hours of employment by the employee, spouse or dependent, including
a switch between part-time and full-time, a strike or lockout, a change in worksite, or commencement or return from an unpaid
leave of absence.
£ £ Change in eligibility due to change in residency of the employee, spouse or dependent.
Change in Cost or Coverage (applicable for health insurance and dependent care assistance account elections only)
£ £ Significant cost increase in your or your dependent’s coverage.
£ £ Significant curtailment of your or your dependent’s coverage.
£ £ Addition or elimination of benefit package option under your or your dependent’s employer’s plan.
£ £ Change in coverage or open enrollment of spouse or dependent under other employer’s plan provided that the employee,
spouse or dependent elects coverage under the dependent’s plan.
£ £ Dependent care provider is replaced by another.
Please change my election(s) as follows:
Premium Savings Account
Change insurance premiums to $__________ per pay period.
Health Care Expense Account
Change my annual election for my Health Care Expense Account from $__________ to $__________. My new per pay period election
will be $__________ effective with the __________ __________ payroll.
Dependent Care Assistance Program
Change my annual election for my Dependent Care Assistance Program from $__________ to $__________. My new per pay period
election will be $__________ effective with the __________ __________ payroll.
_______________________________________________________
_____________________________________________
Employee signature
Date
Accepted and agreed to by:
_______________________________________________________
_____________________________________________
Company Representative
Date
Section 125 Cafeteria Plan
Change in Status/Termination Election Form
Complete this form when a change in status has occurred which affects your Cafeteria Plan election. All changes must be due to
and consistent with the change in status.
Company name ____________________________________________
Employee name ___________________________________________
Social Security Number ___________________________________
Phone _________________________________________
Employee address __________________________________________________________________________________________
Effective date of change ____________________________
If terminating, date of last deduction _______________________
As a participant in the Cafeteria Plan, I am entitled to revoke my prior benefits election and enter into a new election in the event of certain
changes in status. I understand that the change in my benefits election must be due to and consistent with the change in status and that the
change must be acceptable under the Regulations issued by the Department of Treasury.
I certify that I have incurred the following change in status:
Change in Marital Status
£ £ Change in legal marital status including marriage, death of the spouse, divorce, legal separation or annulment.
Change in Number of Tax Dependents
£ £ Change in the number of tax dependents including birth, adoption, placement for adoption or death of a dependent.
Changes in Spouse or Dependent’s Eligibility Under an Employer’s Plan
£ £ Change in dependent status in satisfying or ceasing to satisfy the eligibility requirements of the plan, such as
attainment of limiting age or student status or change in marital status.
£ £ Judgment, decree or order including the imposition of a Qualified Medical Child Support Order.
£ £ Gain or loss of Medicaid or Medicare entitlement.
£ £ Entitlement to COBRA.
£ £ Special requirements relating to the Family and Medical Leave Act (FMLA).
Change in Employment Status that Changes Eligibility Status
£ £ Change of employment status, such as termination or commencement of employment by the employee, spouse or dependent.
£ £ Change in work schedule, such as a reduction or increase in hours of employment by the employee, spouse or dependent, including
a switch between part-time and full-time, a strike or lockout, a change in worksite, or commencement or return from an unpaid
leave of absence.
£ £ Change in eligibility due to change in residency of the employee, spouse or dependent.
Change in Cost or Coverage (applicable for health insurance and dependent care assistance account elections only)
£ £ Significant cost increase in your or your dependent’s coverage.
£ £ Significant curtailment of your or your dependent’s coverage.
£ £ Addition or elimination of benefit package option under your or your dependent’s employer’s plan.
£ £ Change in coverage or open enrollment of spouse or dependent under other employer’s plan provided that the employee,
spouse or dependent elects coverage under the dependent’s plan.
£ £ Dependent care provider is replaced by another.
Please change my election(s) as follows:
Premium Savings Account
Change insurance premiums to $__________ per pay period.
Health Care Expense Account
Change my annual election for my Health Care Expense Account from $__________ to $__________. My new per pay period election
will be $__________ effective with the __________ __________ payroll.
Dependent Care Assistance Program
Change my annual election for my Dependent Care Assistance Program from $__________ to $__________. My new per pay period
election will be $__________ effective with the __________ __________ payroll.
_______________________________________________________
_____________________________________________
Employee signature
Date
Accepted and agreed to by:
_______________________________________________________
_____________________________________________
Company Representative
Date