Benefit Election Change Form

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Miami-Dade County
For Office Use Only
BENEFIT ELECTION CHANGE
Flex Approval: YES NO
FORM
Effective Date:_________
Group #: ____________
Attach a Flex Change In Status Form if changing a pre-tax
benefit election due to a valid qualifying event.
st
R
eturn form to: Benefits Administration\Human Resources Dept., SPCC - 111 NW 1
Street, Suite 2340, Miami, FL 33128
Phone (305) 375-4288
Fax (305) 375-2964
Employee Last Name
First Name
Social Security#
MI
(Print)
(Print)
Department
Phone Number
Cell Phone
Change requests are processed prospectively and premium changes, if any, take effect the beginning of the next pay period following
.
receipt of your request. For exceptions and related information, refer to the Benefits
Handbook at
)
1.  ADD DEPENDENT(S)
 CANCEL DEPENDENT(S)
(Check one box only
Qualifying Event (QE) Type______________________________________________________ QE DATE_________________
Comments ___________________________________________________________________________________________
Date of Birth
Gender
Relationship
Provider ID#
LAST NAME
FIRST NAME
SOCIAL SEC #
MMDDYYYY
Spouse\DP
Male
Female
Child
Male
Female
Male
Child
Female
Male
Child
Female
Male
Child
Female
2.  CANCEL PLAN ELECTIONS - Complete this section only if you wish to OPT-OUT OF PARTICIPATION IN A BENEFIT
PLAN.
 OPTIONAL LIFE
 MEDICAL PLAN
 DENTAL PLAN
 VISION PLAN
 GROUP LEGAL
 SHORT-TERM DISABILITY
 LONG-TERM DISABILITY
After open enrollment, you may cancel any post-tax benefit plan (Group Legal, Short-Term, or Long-Term Disability Plans) without a penalty. If you
cancel a pre-tax benefit plan subject to the IRC Section 125 salary reduction provisions, such as medical, dental and vision, you will still be required
to pay the employee premium (if any) for the remainder of the year. Once you cancel any benefit plan (pre-tax or post-tax), you will not have
another opportunity to re-enroll until the next open enrollment, unless you experience a family status change or HIPAA qualifying event. Your
signature below acknowledges that you understand and agree to these conditions.
3.  NAME CHANGE
From
To
Effective
Signature_
Date
______________________________________________________________________________
_________________________________
Plan Status Change 01/05/15
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