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Online Qualified Status Change Form
Please use this online form to submit the Qualified Status Change.
Employer Name*
Employee Name*
last 4 of Social Security Number*
Birthday*
______________________________
Date Event Occurred*
Status Change Reasons*
Select one
Change in legel marital status
Birth of child
Death of a dependent
Adoption of a child
Change in dependent eligibility
Daycare amount changes by 10% or more
You enrolled your child in a different plan
Change in daycare provider
Employment status change that affects eligibility for health insurance benefits for you, your spouse, or any dependent
Change in residence required by my employer affecting eligibility
Other: Please explain below
If selected other please explain below
______________________________
As a result of the change indicated above, I am requesting the following:
Select One
Cancel my current election
Elect to participate
To replace my current election with a new election
Pay Frequency*
Select One
Weekly - 52
Bi Weekly - 26
Semi Monthly - 24
Monthly - 12
Old per pay election*
New per pay election*
Account type*
Select one
DCA - Dependent Care Reimbursement Account
FSA - Flexible Spending Account
HC2 - Limited Flexible Spending Account
HRA - Health Reimbursement Account
LHRA - Limited Health Reimbursement Account
HSA - Health Savings Account
WEL - Wellness Account
IIR - Premium Reimbursement Account
TRN - Transportation Account
______________________________
Name of person Submitting the Status change*
Email address of person submitting status change*
Submit
* Required
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