Select Page

Employee Change of Status Form

Employee Change of Status Form

After filling out form, please scroll to the bottom and hit Submit.

Fill out a separate Change of Status Form for each benefit election change requested.

    Employer Name

    Date

    Employee Name

    Division

    Please Read: Before submitting this form, check the Change of Status matrix distributed with the Summary Plan Description to see if the change in election you are requesting is acceptable for your change in status. You must submit a Change of Status Form within 30 days of the changing event.

    I want to replace an existing election with a new election.

    Effective on pay period:

    Effective date cannot be before the later of date of event or the date form is signed and received by plan administrator.

    Existing benefit election

    Deduction Amount per Pay Period:

    New Benefit Election

    Deduction Amount per Pay Period:

    My event is:

    Event Date

    Code

    I want to

    Effective on pay period

    Effective date cannot be before the later of date of event or the date form is signed and received by plan administrator.

    Deduction Amount per Pay Period

    Benefit Election

    My event is:

    Event Date

    Code

    I certify that I have had the above change in status and request that changes in my elections be made as indicated. In no event may the actions be effective before the first pay period beginning after this form is completed and returned to MY EMPLOYER.

    Following is a list of acceptable events for changing your elections.  Please check the Change of Status Matrix distributed with the Summary Plan Description to see if the requested change in elections is acceptable and consistent with your change in status.  The change in elections cannot be effective before this form is signed and returned to the Plan Administrator.  You must submit a change of status form within 30 days of the change in status.

    Code Event

    1. Marriage
    2. Gain dependent: Birth - Adoption - Foster Child - Dependent Gains  Eligible Status - QMCSO
    3. Lose spouse: Divorce - Legal Separation - Death of Spouse
    4. Lose 1 or more dependents
    5. Spouse gains job.
    6a. Employee, spouse, or dependent gains Major Medical coverage through employment change.
    6b. Employee, spouse, or dependent gains Supplemental Medical coverage through employment change.
    6c. Employee, spouse, or dependent gains Health FSA coverage through employment change.
    7. Spouse loses job.
    8a. Employee, spouse, or dependent loses Medical coverage through employment change.
    8b. Employee, spouse, or dependent loses Supplemental Medical coverage through employment change.
    8c. Employee, spouse, or dependent loses Health FSA coverage through employment change.
    9. Spouse takes unpaid leave of absence.
    10. Spouse returns from leave of absence.
    11. Pay increase or decrease.
    12. Pay shortage;
    13. Employee taking unpaid leave of absence (other than FMLA).
    14. Employee taking unpaid leave of absence (FMLA).
    15. Return from unpaid leave of absence (other than FMLA).
    16. Return from FMLA unpaid leave of absence.
    17. Termination and rehire within 30 days.
    17a. Termination and rehire after 30 days.
    18. Short-term Disability (absence with pay)
    19. Termination of Employment (flex enrollment ceases).
    20. Emloyee moves from flex-ineligible to flex-eligible.
    21. Move from flex-eligible to flex-ineligible status (flex enrollment ceases) - e.g., full-time to part time.
    22. Employee moves from part-time benefits eligible to full time.
    23. Employee moves from full-time to part-time benefits ineligible.
    24. Spouse moves from full-time to part-time.
    25. Spouse moves from part-time to full-time.
    26. Geographic relocation withuin flex (considered to have occurred only if current coverage not available in new location).
    27. Transfer from non-flex subsidiary.
    28. Transfer to non-flex subsidiary.
    29. Changes in employee's or spouse's work shift eliminates or necessitates dependent care.
    30. Dependent child moves outside HMO service area due to relocation of custodial parent who is not employee.