Employer:
Employee:
Address:
City:
State:
Zip:
Qualifying Event Date:
 
Medical: Yes      No
   Coverage Type:
EEEE/SP
EE/CHFamily
   Current Rate:
 
Dental: Yes      No
   Coverage Type:
EEEE/SP
EE/CHFamily
   Current Rate:
 
Vision: Yes      No
   Coverage Type:
EEEE/SP
EE/CHFamily
   Current Rate:
 
FSA: Yes      No
   Remaining Balance:
Qualifying Events
New Hire (initial notice)
Quit
Lay Off
Termination
Reduction of hours
Dependent child
Divorce / Legal Separation / Death
Medicare
Termination of COBRA coverage