Shaffer Insurance Services, Inc.

  • 902 E Avenue, Q-9
  • Palmdale, CA 93550
  • Phone: 661-410-7048
  • Fax: 661-274-4272

Office Hours:

Mon: 9:00 AM – 5:00 PM
Tues: 9:00 AM – 5:00 PM
Wed: 9:00 AM – 5:00 PM
Thurs: 9:00 AM – 5:00 PM
Fri: 9:00 AM – 4:00 PM
Sat: Closed
Sun: Closed

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661-410-7048

Notification of Terminations to the 125 Plan

Notification of Terminations to the 125 Plan


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

Employer
Date (MM/DD/YY)
Prepared By:
Work Phone

Employee 1

Name and last 4 digits of SS#
Termination Date
Last Pay Period withheld:
YTD Total
Benefits Terminated: (Example):FSA Medical Group Help

Employee 2

Name and last 4 digits of SS#
Termination Date
Last Pay Period withheld:
YTD Total
Benefits Terminated: (Example):FSA Medical Group Help

Employee 3

Name and last 4 digits of SS#
Termination Date
Last Pay Period withheld:
YTD Total
Benefits Terminated: (Example):FSA Medical Group Help

Employee 4

Name and last 4 digits of SS#
Termination Date
Last Pay Period withheld:
YTD Total
Benefits Terminated: (Example):FSA Medical Group Help
Please notify us immediately of all Terminations. It's very important that we know if the employee was on FSA Medical or Dependent Care Care Assistance program so that a reimbursement check does not go out unaccounted for.