Enrollment-Change Notification Form Hra/fsa/transit And Parking Benefits Plans
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1
2Enrollment/Change Notification Form
HRA/FSA/Transit and Parking Benefit Plans
Directions: This form is used to enroll a new employee, make an enrollment status or a benefit change. The employer must complete
the following steps to successfully process the change:
1.
Section 1, 2, and 3 must be completed for any changes
2.
Select required change type ( Section 4: Enrollment Status Change, Section 5: Benefit Plan Change or Section 6: Election
3.
Submit the completed form to:
sm
UnitedHealthcare Benefit Services
P.O. Box 2490
Brookfield, WI 53008-2490
Phone:
(800) 318-5311
Fax:
(800) 760-3727
(The HRA/FSA/Transit and Parking form may be completed on-line.)
Web:
1
Type of Change Requested - REQUIRED
(please describe the type of change being requested)
Enrollment Status Change
Benefit Plan Change/Election
New Hire Benefit Election
Employee Name Change
Employee Termination of Plan(s)
Employee Benefit Election Change
Employee Address Change
Flexible Spending Account (FSA)
Flexible Spending Account (FSA)
Employee Enrollment Status Change (HRA only)
Health Reimbursement Arrangement (HRA)
Dependent Day Care
Employee Termination Notification (not COBRA)
Dependent Day Care
Private Insurance
Transit & Parking (Section 132)
Health Reimbursement Arrangement (HRA)
Employee Unpaid Leave of Absence Notification
Private Insurance
Transit & Parking (Section 132)
Employee Leave of Absence Return Notification
Change Effective Date (mm/dd/yyyy):
2
Employee Demographics – REQUIRED
Employee Name (Last, First, Middle initial)
Social Security Number
Email Address
Home Address (Street and Apt. Number) , ,
City
State
Zip Code
3
Employer Signature and Acknowledgment – REQUIRED
I acknowledge as an Employer Representative that this Flexible Benefit Plan Change Notification Form should be processed for the reasons
selected in Section 1.
Employer Signature
Date
Employer Name
Phone Number
UHC Policy Number
4
Enrollment Status Change-
only complete the section that applies to the enrollment status change
Employee Name and Address Change
Prior Name (Last, First, Middle Initial)
New Name (Last, First, Middle Initial)
New Email Address
New Employer Branch Location Code
New Phone Number
Home Address (Street and Apt. Number) , ,
City
State
Zip Code
Employee Enrollment Status Change-HRA Only
Current Coverage Status
Single Coverage
Employee & Spouse
Employee & Dependent(s)
Family
Number of Children ____________
New Coverage Status Change
Single Coverage
Employee & Spouse
Employee & Dependent(s)
Family
Number of Children ____________
Reason For Change
Marriage
Divorce
New Dependent
Loss of Dependent
Death of Spouse
Leave of Absence
Return from Leave of Absence
Other ___________________________________________________________________________
Employee Leave of Absence Change
Employee Initiated Unpaid Leave of Absence Notification
Leave of Absence Start Date: _____/_____/________
Employee Returned from Leave of Absence
Return Date:
_____/_____/________
N/A
UnitedHealthcare Benefit Services Benefit Plan Enrollment/Change Notification Form 04/08
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