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F3927R07 (02/18) QUALIFYING EVENT NOTIFICATION FORM Group Information Group Name: Group ID#: Employee Information (Please Print) Spending Account ID # Last Name First Name Middle Initial S A Street Address Social Security # (if SA# is not known) City State Zip Daytime Phone # Qualifying Event Information I have experienced a change in status as indicated below. The effective date of change is: (You have a limited time period to submit this change. Discuss with your benefits department to determine the time period.) Change affects: l Self l Spouse l Dependent 1. Employment Status Change l Termination of employment l Full-time to Part-time l Leave of Absence (unpaid) l Commencement of employment l Part-time to Full-time l Continuation through COBRA (for Medical Expense Reimbursement Only) 2. Marital Status Change l Marriage l Legal Separation l Divorce l Widowed 3. Dependent Status Change l Birth l Adoption l Death 4. l Other: _ Due to the Qualifying Event indicated above, I am requesting that my Further enrollment for this plan year be changed. (Election amounts cannot be lowered if your employee (self) is terminating employment) Current Annual Election Current Per Pay Period Deduction Amount From: l Medical Expense $ $ l Dependent/Day Care Expense $ $ l Premium Reimbursement Expense $ $ New Annual Election New Per Pay Period Deduction Amount To: l Medical Expense $ $ l Dependent/Day Care Expense $ $ l Premium Reimbursement Expense $ $ Groups who submit onfile payroll information must update their onfile payroll worksheet accordingly. Employee Signature - Not required for terminating employees (self) I certify that the status change as noted above has occurred. I authorize that my enrollment records be changed or cancelled as requested. Employee’s Signature Print Name Date Group Signature Group Signature Date Questions? Call Group Leader Services at 1-[PHONE REDACTED]. Send via secured email only: [EMAIL REDACTED] Fax to: [PHONE REDACTED] Mail to: P.O. Box 64193 St. Paul, MN 55164-0193