Change In Status/termination Election Form
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1Change in Status/Termination Election Form
Section 125 Cafeteria Plan
Complete this form when a change in status has occurred which affects your Cafeteria Plan election. All changes must be
due to and consistent with the change in status.
Company name_______________________________________
Employee name ______________________________________
Social Security Number________________________________ Phone_____________________________________
Employee address _______________________________________________________________________________
Effective date of change ________________________
If terminating, date of last deduction ____________________
As a participant in the Cafeteria Plan, I am entitled to revoke my prior benefits election and enter into a new election in the event of
certain changes in status. I understand that the change in my benefits election must be due to and consistent with the change in status
and that the change must be acceptable under the Regulations issued by the Department of Treasury.
I certify that I have incurred the following change in status:
Change in Marital Status
Change in legal marital status including marriage, death of the spouse, divorce, legal separation or annulment.
Change in Number of Tax Dependents
Change in the number of tax dependents including birth, adoption, placement for adoption or death of a dependent.
Changes in Spouse or Dependent’s Eligibility Under an Employer’s Plan
Change in dependent status in satisfying or ceasing to satisfy the eligibility requirements of the plan, such as attainment of
limiting age or student status or change in marital status.
Judgment, decree or order including the imposition of a Qualified Medical Child Support Order.
Gain or loss of Medicaid or Medicare entitlement.
Entitlement to COBRA.
Special requirements relating to the Family and Medical Leave Act (FMLA).
Change in Employment Status that Changes Eligibility Status
Change of employment status, such as termination or commencement of employment by the employee, spouse or dependent.
Change in work schedule, such as a reduction or increase in hours of employment by the employee, spouse or dependent,
including a switch between part-time and full-time, a strike or lockout, a change in worksite, or commencement or return from an
unpaid leave of absence.
Change in eligibility due to change in residency of the employee, spouse or dependent.
Change in Cost or Coverage (applicable for health insurance and dependent care assistance account elections only)
Significant cost increase in your or your dependent’s coverage.
Significant curtailment of your or your dependent’s coverage.
Addition or elimination of benefit package option under your or your dependent’s employer’s plan.
Change in coverage or open enrollment of spouse or dependent under other employer’s plan provided that the employee,
spouse or dependent elects coverage under the dependent’s plan.
Dependent care provider is replaced by another.
Change in Election due to Discrimination Testing
Reduction in elections to comply with nondiscrimination rules.
Please change my election(s) as follows:
Premium Savings Account
Change insurance premiums to $__________ per pay period.
Health Care Expense Account
Change my annual election for my Health Care Expense Account from $__________ to $__________.
My new per pay period election will be $__________ effective with the __________ __________ payroll.
Dependent Care Assistance Program
Change my annual election for my Dependent Care Assistance Program from $__________ to $__________.
My new per pay period election will be $__________ effective with the __________ __________ payroll.
___________________________________________________
_________________________________________
Employee signature
Date
Accepted and agreed to by:
___________________________________________________
_________________________________________
Company Representative
Date
1105
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