FLEXIBLE SPENDING HEALTH CARE REIMBURSEMENT ACCOUNT
AGREEMENT UPON TERMINATION
EMPLOYEE NAME:
COMPANY NAME:
SOCIAL SECURITY NUMBER:
TERMINATION DATE:
If you have a positive balance (payroll deductions are greater than the amount you have received in
reimbursement) in your Flexible Spending Health Care Reimbursement Account at the time of termination, you
may continue participation in the Plan for the remainder of the Plan Year. If you want to remain in the Plan, you
can do so by selecting one of the COBRA options below. If you prefer to terminate your participation and
contribution to the Plan, any balance in your account on your date of termination will be forfeited if expenses were
not incurred prior to your date of termination.
I elect to terminate participation in the Flexible Spending Health Care Reimbursement
Account. I understand that I can submit claims for eligible medical expenses that were
incurred prior to my termination. If I do not have sufficient claims that were incurred prior to
my termination to exhaust my account balance, any unused balance will be forfeited.
COBRA CONTINUATION WITH PRETAX CONTRIBUTIONS
I elect COBRA for the Flexible Spending Health Care Reimbursement Account. The
remaining contributions for the period indicated below (select one) will be deducted from
my final paycheck.
Remainder of the Plan Year
Through the month of (List month that you want
COBRA Coverage through)
COBRA CONTINUATION AFTER TAX CONTRIBUTIONS
I elect COBRA for the Flexible Spending Health Care Reimbursement Account and will pay
you with after-tax dollars on a monthly basis.
EMPLOYEE SIGNATURE: DATE:
Please submit this form to your Employer.
HCR/ Agreement Upon Termination Form 11.05.2015
