Employer Request Forms Flex Facts

Employee Termination
Company Name/Address Change
Election Change
Add Authorized Contact
Remove Authorized Contact

Employee Termination

Date of Termination:

Date of Last Payroll Deduction:

YTD deduction amount prior to termination:

Flex Facts Terminated Employee Claims Policy

Address Change

New Name:

New Phone Number:

New Address:

City:

State:

Zip:

Add Authorized Contact

Name:

Title:

New Contact's Four Digit Pin:

Company:

Phone:

Email:

Reason for Change:

Change Detail:

Benefit Type:

Payroll Date of Change:

Current Annual Election:

Annual Election After Change:

Current Per Pay Election:

Per Pay Election After Change:

YTD Deduction Amount Prior to Election Change:

Are you making changes to any other elections?

Yes No

Reason for Change:

Your benefit change must be consistent with the reason given above and must be allowed by the Change in Status regulations. We will review your request and submit a determination to you if the change is no approved.

Change Detail:

Benefit Type:

Payroll Date of Change:

Current Annual Election:

Annual Election After Change:

Current Per Pay Election:

Per Pay Election After Change:

YTD Deduction Amount Prior to Election Change:

Are you making changes to any other elections?

Yes No

Reason for Change:

Change Detail:

Benefit Type:

Payroll Date of Change:

Current Annual Election:

Annual Election After Change:

Current Per Pay Election:

Per Pay Election After Change:

YTD Deduction Amount Prior to Election Change:

Are you making changes to any other elections?

Yes No

Reason for Change:

Change Detail:

Benefit Type:

Payroll Date of Change:

Current Annual Election:

Annual Election After Change:

Current Per Pay Election:

Per Pay Election After Change:

YTD Deduction Amount Prior to Election Change:

Are you making changes to any other elections?