Employers

Employer Forms

Employee Change/Termination Form
This form is used when there is a change in an employee's status. Examples of this are: Class or Position, Beneficiary Change, Name Change/Conversion, Rehire(enrollment may be required), Leave of Absence, Salary Termination
Self-Funded Group Enrollment Form
This form is used to enroll employees and dependents for health, dental, vision, life or STD coverage.
Flexible Spending Account Termination Form
This form is used to terminate an employee's Flexible Spending Account.
Premium Only Plan / Flexible Spending Account Employer Application
This form is used to enroll a new Premium Only Plan and/or Flexible Spending Account plan for an employer. This form is not to be used for enrolling employees in an existing Flexible Spending Account plan.
Flexible Spending Account Employee Application
This form is used to enroll employees for Flexible Spending Account benefits. Important note to employers with option for direct deposit: Contact the Policy Administration Department for the correct enrollment form.
Employer Statement Form
This form is used to verify information for disability claims.
Flexible Spending Account Change of Status Form
This form is used to add a dependent or revise an employee's pledge amount. Do not use this form to terminate FSA benefits. Use the FSA Termination Form for that purpose.
Notice of Conversion Rights
This form is used to inform about conversion rights when coverage is terminated. Conversion information can be requested from this form.