Fruitland School District #373 COBRA Termination

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Note: This form is completed when there is a "Termination" of an Employee from your Employer Benefits Plans.

** Indicates Required Fields.

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Employer Information

Note: You will need to contact your FSA Administrator, American Fidelity to obtain this detail, so FSA COBRA can be administered properly. Do not rely on reporting, because reports can change due to claims processing. Contacting the administrator ensures accurate YTD detail.

Employee Information
Additional Information
Spouse/Dependent(s) Information

Note: When a spouse and/or dependent(s) are enrolled in the benefit plan(s), please be sure to provide their name and requested information when enrolled.

Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dependent 6
Dependent 7

Date of Signature

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