Florida Combined Life Fsa Employee Change Form
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1
2F
C
L
LORIDA
OMBINED
IFE
MAIL TO:
FLORIDA COMBINED LIFE
F
E
C
F
Pre -Tax Department
SA
MPLOYEE
HANGE
ORM
PO Box 45132
Jacksonville, FL 32232-5132
TOLL-FREE 1-800-434-8026
Company Name: ______________________________________________________________ Group
#:____________________*
(Insert Name of Overall Benefit Plan Sponsor)
q
q
q
q
Type of Change:
Change in Contribution/Participation
Name Change
Address change
Termination
(Last)
(First)
(MI)
Employee Name:
Street Address:
City
State
Zip
Social Security Number:
TERMINATION
(To be completed by employer)
MEDICAL
DEPENDENT CARE
Termination Date:
Termination Date:
Final Payroll Deduction Date:
Final Payroll Deduction Date:
YTD Deduction Amount:
$
YTD Deduction Amount:
$
(Complete reverse side for Contribution Changes and Leaves of Absence)
SIGNATURE
Ä
Employee Signature:
Date:
Ä
Authorized Signature (Company Representative)
Date:
* To be completed by Group Benefits/Human Resources Staff. Use Blue Cross Blue Cross Blue Shield of Florida numbering, when
available; internal numbering when not.
FSA Employee Change Form
Rev. 09/02
51090-600RPS
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Parent category: Business