Fax: 877-641-5956
Phone: 501-941-5956
Cabot, AR 72023
P.O. Box 1513
Change of Status Form
First Name
Last Name:
Check here if new address
I certify that I experienced the above change of status events. I certify the statement and information on this change of status form are
accurate and true.
Employee Signature: Date:
Mail form to: P.O. Box 1513, Cabot AR 72023; Fax claims to: 877-641-5956; or E-mail claims to:
For questions regarding your claims please call: 501-941-5956
Fill out the top and bottom sections of this form.
Choose the applicable sections to fill out in the
middle of the form. This form must be
submitted within 30 days of your event change.
For additional information on IRS status changes
please refer to the Change of Status Matrix.
Replace Current Election
I want to replace an existing election with a new election
Existing Benefit: Existing Deduction Amount:
New Benefit: New Deduction Amount:
Change of Status Event:
Event Date: Payroll Effective Date:
Terminate Election
I want to terminate a Benefit Election
Terminating Benefit:
Event Date:
Change of Status Event:
New Election
I want to add a new election
Change of Status Event:
New Benefit
Employer Signature: Date:
Payroll Effective Date:
Event Date: Payroll Effective Date:
Check here for name change
Print Form
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