C.O.B.R.A. ELECTION FORM |
-For Continued 125
(Cafeteria) Plan Benefits- |
Employee
Information:
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Employee: |
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Social Security #: |
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Last Name |
First Name |
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Address: |
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Street |
City |
State |
Zip Code |
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Home Phone: |
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Work Phone: |
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E-mail: |
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Qualifying
Event Information:
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*Please select
one of the following and put an ' x' in the appropriate box |
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Termination of Employment |
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employee has become eligible for medicare |
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Reduction in work hours |
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attainment of limiting age (for
dependents) |
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Death of Employee (Coverage
may be continued by dependents) |
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filing of chapter 11 - Bankruptcy |
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divorce or legal separation |
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Disability |
Application
for:
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Monthly
Amounts:
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I hereby apply for continued 125 (Cafeteria) Plan
benefits under the continuation of coverage legislation of the Consolidated
Omnibus Budget Reconciliation ACt of 1985
(COBRA). I agree to submit funds to my employer out of my after-tax
income, and understand that if these funds are not received, by the employer,
within 30 days of the covered month, my coverage will terminate and cannot be
reinstated. I understand that the length of time that I may be covered
will be determined by either failing to submit my monthly funds or by the end
of my employer's plan year. |
Employee Signature: |
__________________________________________ |
Date: |
____________________________ |
HR director Signature: |
__________________________________________ |
Date: |
___________________________ |
HR director name (printed): |
_________________________________________ |
Please Print, Sign, & Mail this form to: |
Fcf Benefits & Administration: 2494 E. Kays
Creek Dr. Layton, Ut 84040 |
*Note: Your Human Resources Director must sign this form
before it can be processed by FCF Benefits & Administration |