Form | Email: Forms@myMidAmerica.com | Fax: (863) 577-4460
Change of Status Election Form
Return this completed form to:
Mail: MidAmerica Administrative & Retirement Solutions
PO Box 149, Lakeland, FL 33802-0149
Email: Forms@myMidAmerica.com
| Ph: (800) 430‐7999
Employer Social Security Number
Fi
rst Name Last Name M.I. Date of Birth (MM/DD/YYYY)
Mailing Address City State Zip
Email Address Telephone
Choose carefully as your election is binding for the entire Plan Year. Any unused dollars remaining in your Flexible Spending Account at the end of
the Plan Year will be forfeited. Expenses/claims must be incurred during the Plan Year in order to be eligible for reimbursement. See the Summary
Plan Description for more details.
BENEFIT CURRENT CURRENT PER PAY PERIOD NEW NEW PER PAY PERIOD
ANNUAL ELECTION WITHHOLDING ANNUAL ELECTION WITHHOLDING
Health Care Reimbursement $_______________ $_______________ $_______________ $_______________
Dependent Care Reimbursement $_______________ $_______________ $_______________ $_______________
Valid qualifying events (QE) include, but not limited to:
Change in employment status (beginning/end of employment of a
spouse resulting in gain or loss of insurance coverage)
Change in your legal marital status (marriage, divorce, death of
spouse)
Change in number of tax dependents (birth, adoption/placement for
adoption, gain/loss of dependent eligibility, death of dependent)
Change in coverage, cost or provider. This applies only to
Dependent Care.
Gai
n or loss of other group health coverage
(Medicare/Medicaid, COBRA)
Judgement, decree or court order
Unpaid leave of absence
Change from part-time to full-time employment status or
vice versa
*Please note: You must make your election within 30 days of the qualifying event.
Please note: You must submit supporting documentation corresponding with the QE such as marriage, death, or birth certificate; divorce decree; letter from employer
or childcare provider substantiating employment status or change in coverage, cost or provider, respectively.
I hereby am amending my Flexible Benefits Plan election; therefore, I authorize my Employer to reduce my wages on a pretax basis during each
payroll period in the amount noted above. I understand this election will be in effect for only the current plan year. I understand I must complete
each year.
I under
stand that I cannot revoke or change this election during the Plan Year unless there is another change in status qualifying event that
affects my or my dependents’ eligibility under this Plan or another employer plan. The rules regarding election changes are described in more
detail in the Summary Plan Description.
I under
stand that I must submit a claim and appropriate substantiating documentation (e.g. explanation of benefits, itemized bill) for out-of-pocket
medical, and/or Dependent Care expenses before I can be reimbursed. I certify that I will only submit claims for reimbursement under the Flexible
Spending Account Plan. I certify that I will not submit claims for reimbursement under the Flexible Spending Account Plan for amounts that have
already been reimbursed by another source nor will I seek reimbursement for such amounts from any other source.
Participant Signature
Signature Date (MM/DD/YYYY)
Print Form
Clear Form
A change of election must be on account of and corresponding to a change in status that affects eligibility for coverage or
expenses as acceptable under Regulations issued by the Department of Treasury. The change of status must be made within 30
days of the qualifying event.
REASON FOR CHANGE (QUALIFYING EVENT)
NOTE: Enter effective date of coverage: _______________
PARTICIPANT CERTIFICATION & SIGNATURE
NOTE: Enter date of change in status*_________________
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