Fruitland School District #373 COBRA Termination

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

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Employer Information

Hire Date**

Termination Date**

Plan Type (Check all that apply)**

Medical

Dental

Vision

Enrolled in an FSA?**

Yes

FSA Annual Election Amount $**

YTD FSA Contribution Total $**

YTD FSA Claims Reimbursment Total $**

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.

Medical Plan Enrollment**

Medical Enrollment**

Dental Plan Enrollment**

Dental Enrollment**

Vision Plan Enrollment**

Vision Enrollment**

Employee Information

First Name**

M.I.

Last Name**

Social Security Number**

Date of Birth**

Most Recent Mailing Address**

City**

Zip Code**

Best Contact Phone**

Additional Information

Employee Type of Qualifying Event**

Reduction in Hours

Involuntary Termination

Voluntary Termination

Dependent Qualifying Event**

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.

Remove Spouse?**

Yes

Spouse

First Name**

M.I.

Last Name**

Relationship**

Notes

Group Contact Email**

Signature of Group Contact Person**

Date of Signature

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Fruitland School District #373 COBRA Termination