"Employee Change of Status Form"

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E
C
S
F
MPLOYEE
HANGE OF
TATUS
ORM
Fill out a separate Change of Status Form for each benefit election change requested.
EMPLOYER NAME____________________________________
D
: ________________
ATE
E
N
: ___________________________________________________________________________
MPLOYEE
AME
SSN: ______________________________________
D
: ____________________________________
IVISION
: Before submitting this form, check the Change of Status matrix distributed with the Summary Plan Description
P
LEASE READ
to see if the change in election you are requesting is acceptable for your change in status. You must submit a Change of Status
Form within 30 days of the changing event.
I want to replace an existing election with a new election effective on pay period ___________
.
EFFECTIVE DATE CANNOT BE BEFORE THE LATER OF DATE OF EVENT OR THE DATE FORM IS SIGNED AND RECEIVED BY PLAN ADMINISTRATOR
Existing Benefit Election: _________________________________________
Deduction Amount per Pay Period: $ ______________________
New Benefit Election: ____________________________________________
.
Deduction Amount per Pay Period: $ ______________________
My event is: ____________________________________________________________________________
________
_____________________________________________ Event Date: _______________ Code
effective on pay period: ___________________________
I want to
ADD A NEW ELECTION
effective on pay period: ________________________
TERMINATE AN ELECTION
.
EFFECTIVE DATE CANNOT BE BEFORE THE LATER OF DATE OF EVENT OR THE DATE FORM IS SIGNED AND RECEIVED BY PLAN ADMINISTRATOR
Deduction Amount per Pay Period: $ ______________________
Benefit Election: ________________________________________________
My event is: _____________________________________________________________________
_____________________________________________ Event Date: _______________ Code _________
I certify that I have had the above change in status and request that changes in my elections be made as indicated.
In no event may the actions be effective before the first pay period beginning after this form is completed and
returned to MY EMPLOYER.
Employee Signature: _________________________________________
Date: ___________________
EMPLOYER A
C
R
CCEPTANCE OF
HANGE
EQUEST
(C
PAYROLL DEPT.
)
OMPLETED BY
AS AUTHORIZED
Change in deductions made on Pay Period No. _____________ Pay Date: ___________________________
Authorized Signature: __________________________________________
Date: ___________________
SHAFFER INSURANCE SERVICES INC. C
E
R
HANGE
NTRY
ECORD
Change in deductions made on Pay Period No. _______ Pay Date: __________
Signed: ______________________________________________________
Date: ___________________
E
C
S
F
MPLOYEE
HANGE OF
TATUS
ORM
Fill out a separate Change of Status Form for each benefit election change requested.
EMPLOYER NAME____________________________________
D
: ________________
ATE
E
N
: ___________________________________________________________________________
MPLOYEE
AME
SSN: ______________________________________
D
: ____________________________________
IVISION
: Before submitting this form, check the Change of Status matrix distributed with the Summary Plan Description
P
LEASE READ
to see if the change in election you are requesting is acceptable for your change in status. You must submit a Change of Status
Form within 30 days of the changing event.
I want to replace an existing election with a new election effective on pay period ___________
.
EFFECTIVE DATE CANNOT BE BEFORE THE LATER OF DATE OF EVENT OR THE DATE FORM IS SIGNED AND RECEIVED BY PLAN ADMINISTRATOR
Existing Benefit Election: _________________________________________
Deduction Amount per Pay Period: $ ______________________
New Benefit Election: ____________________________________________
.
Deduction Amount per Pay Period: $ ______________________
My event is: ____________________________________________________________________________
________
_____________________________________________ Event Date: _______________ Code
effective on pay period: ___________________________
I want to
ADD A NEW ELECTION
effective on pay period: ________________________
TERMINATE AN ELECTION
.
EFFECTIVE DATE CANNOT BE BEFORE THE LATER OF DATE OF EVENT OR THE DATE FORM IS SIGNED AND RECEIVED BY PLAN ADMINISTRATOR
Deduction Amount per Pay Period: $ ______________________
Benefit Election: ________________________________________________
My event is: _____________________________________________________________________
_____________________________________________ Event Date: _______________ Code _________
I certify that I have had the above change in status and request that changes in my elections be made as indicated.
In no event may the actions be effective before the first pay period beginning after this form is completed and
returned to MY EMPLOYER.
Employee Signature: _________________________________________
Date: ___________________
EMPLOYER A
C
R
CCEPTANCE OF
HANGE
EQUEST
(C
PAYROLL DEPT.
)
OMPLETED BY
AS AUTHORIZED
Change in deductions made on Pay Period No. _____________ Pay Date: ___________________________
Authorized Signature: __________________________________________
Date: ___________________
SHAFFER INSURANCE SERVICES INC. C
E
R
HANGE
NTRY
ECORD
Change in deductions made on Pay Period No. _______ Pay Date: __________
Signed: ______________________________________________________
Date: ___________________
Following is a list of acceptable events for changing your elections. Please check the Change of Status
Matrix distributed with the Summary Plan Description to see if the requested change in elections is
acceptable and consistent with your change in status. The change in elections cannot be effective before
this form is signed and returned to the Plan Administrator. You must submit a change of status form
within 30 days of the change in status.
CODE
EVENT
1. Marriage
2. Gain dependent: Birth – Adoption – Foster Child – Dependent Gains Eligible Status –
QMCSO
3. Lose spouse: Divorce – Legal Separation – Death of Spouse
4. Lose 1 or more dependents
5. Spouse gains job.
6a. Employee, spouse, or dependent gains Major Medical coverage through employment
change.
6b. Employee, spouse, or dependent gains Supplemental Medical coverage through
employment change.
6c. Employee, spouse, or dependent gains Health FSA coverage through employment change.
7. Spouse loses job.
8a. Employee, spouse or dependent loses Medical coverage through employment change.
8b. Employee, spouse or dependent loses Supplemental Medical coverage through
employment change.
8c. Employee, spouse or dependent loses Health FSA coverage through employment change.
9. Spouse takes unpaid leave of absence.
10. Spouse returns from leave of absence.
11. Pay increase or decrease.
12. Pay shortage:
13. Employee taking unpaid leave of absence (other than FMLA).
14. Employee taking unpaid leave of absence (FMLA).
15. Return from unpaid leave of absence (other than FMLA).
16. Return from FMLA unpaid leave of absence.
17. Termination and rehire within 30 days.
17a. Termination and rehire after 30 days.
18. Short-term Disability (absence with pay)
19. Termination of Employment (flex enrollment ceases).
20. Employee moves from flex-ineligible to flex-eligible.
21. Move from flex-eligible to flex-ineligible status (flex enrollment ceases)—e.g., full-time
to part-time.
22. Employee moves from part-time benefits eligible to full time.
23. Employee moves from full-time to part-time benefits ineligible.
24. Spouse moves from full-time to part-time.
25. Spouse moves from part-time to full-time.
26. Geographic relocation within flex (considered to have occurred only if current coverage
not available in new location).
27. Transfer from non-flex subsidiary.
28. Transfer to non-flex subsidiary.
29. Changes in employee’s or spouse’s work shift eliminates or necessitates dependent care.
30. Dependent child moves outside HMO service area due to relocation of custodial parent
who is not employee.
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