F3927R07 (02/18)
Group Information
Group Name: Group ID#:
Employee Information (Please Print) Spending Account ID #
Last Name First Name Middle Initial
Street Address
Social Security # (if SA# is not known)
City State Zip
Daytime Phone #
Qualifying Event Information
I have experienced a change in status as indicated below. The effective date of change is: _________________________
(You have a limited time period to submit this change. Discuss with your benets department to determine the time period.)
Change affects: l Self l Spouse l Dependent
1. Employment Status Change
l Termination of employment l Full-time to Part-time l Leave of Absence (unpaid)
l Commencement of employment l Part-time to Full-time
l Continuation through COBRA (for Medical Expense Reimbursement Only)
2. Marital Status Change
l Marriage l Legal Separation l Divorce l Widowed
3. Dependent Status Change
l Birth l Adoption l Death
l Other: ____________________________________________________________________________________________________________
Due to the Qualifying Event indicated above, I am requesting that my Further enrollment for this plan year be changed.
(Election amounts cannot be lowered if your employee (self) is terminating employment)
Current Annual Election Current Per Pay Period Deduction Amount
From: l Medical Expense $ __________________ $ __________________
l Dependent/Day Care Expense $ __________________ $ __________________
l Premium Reimbursement Expense $ __________________ $ __________________
New Annual Election New Per Pay Period Deduction Amount
To: l Medical Expense $ __________________ $ __________________
l Dependent/Day Care Expense $ __________________ $ __________________
l Premium Reimbursement Expense $ __________________ $ __________________
Groups who submit onle payroll information must update their onle payroll worksheet accordingly.
Employee Signature - Not required for terminating employees (self)
I certify that the status change as noted above has occurred. I authorize that my enrollment records be changed or cancelled as requested.
_________________________________________ ______________________________________ ____________________
Employee’s Signature Print Name Date
Group Signature
_______________________________________________________________________________ ____________________
Group Signature Date
Questions? Call Group Leader Services at 1-888-460-4013.
Send via secured email only:
Fax to:
Mail to:
P.O. Box 64193
St. Paul, MN 55164-0193