Request to Change Insurance Coverage

Name: ___________________________________ Social Security #: _______________

I wish to make the following changes to my benefit elections (check at least one in each column):
Action Who Insurance
 Add  Self  Medical
 Drop  Spouse (Please list below)  Vision
 Children/dependent(s) (Please list below) Dental

Name SS# Date of Birth

______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________

Are you currently participating in the FSA program (i.e. having your healthcare premium amount deducted before taxes)?
 Yes  No

If adding insurance, do you wish to participate in the FSA program? ______________________

What life event occurred prompting your request to change your benefit elections? __________
_____________________________________________________________________________

What was the date of the life event? ______________________

Other comments justifying requested change: _________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________

Human Resources will determine if you are eligible to make the requested changes. Note that all requests to change
benefit elections must be done within 30 days of the life event.

_______________________________________________ __________________
Signature Date

Office Use Only

Received in HR by: _________________________________________ Date: ______________

Comments:_____________________________________________________________________
_________________________________________________________________________________________________
___________________________________________________________

________ Abra _______ Carriers ________ Payroll

Routing: HR → Carriers → Payroll HR7, Revised 7/12/2004