Note: This form is completed when there is a "Termination" of an Employee from your Employer Benefits Plans.
** Indicates Required Fields.
if further instruction is needed.
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.
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.
Date of Signature