-For Continued 125 (Cafeteria) Plan Benefits-


Employee Information:


Effective Date of Change:



Social Security #:

Last Name

First Name





Zip Code

Home Phone:

Work Phone:


Qualifying Event Information:

I elect to continue my contributions through C.O.B.R.A. (Consolidated Omnibus Budget Reconciliation Act) because one of the following events has occurred:


*Please select one of the following and put an ' x' in the appropriate box

Termination of Employment

employee has become eligible for medicare

Reduction in work hours

attainment of limiting age (for dependents)

Death of Employee  (Coverage may be continued by dependents)

filing of chapter 11 - Bankruptcy

divorce or legal separation


Application for:

*Please select one, or both, of the following and put an ' x' in the appropriate box

FSA - Medical Reimbursement

Monthly Amounts:

*Please enter your monthly contributions for one or both of the Flexible Spending Accounts

FSA - Medical Reimbursement Amount (Monthly):

Number of months you will be contributing:

Administration fee (Monthly):

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:





HR director Signature:





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