Transcription of 2018 Benefits Program Qualifying Event Change Form
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Employee ID_____ (Required) 1 2018 Benefits Program Qualifying Event Change Form Please Print - Please Complete ALL Applicable Sections If you have any questions, please contact the University of Rochester Office of Total Rewards at (585) 275-2084 or (585) 272-0227 Please return completed forms to: Office of Total Rewards, 60 Corporate Woods, Suite 310, Box 270453, Rochester, NY 14627; Fax: 585-272-0227 or Email: Employee Information Name (Last, First, Initial) Please Print: _____ Address: _____ _____ Gender (M/F): _____ Date of Birth (MM/DD/YYYY): _____ Phone Number: _____ E-mail Address: _____ Marital Status: Single Married Widowed Divorced Please Check Desired Action - Please complete with date of Qualifying Event I am requesting a Change to my Health Care Plan and/or Dental Plan elections due to a Qualifying Event * Date of Qualifying Event : _____ (complete entire form) I am requesting a Change to my Flexible Spending Account (FSA) elections due to a Qualifying Event * Date of Qualifying Event : _____ (complete pages 1, 2, 4 and 6) I am requesting a Change to my annual Health Savings Account election (University HSA-Eligible)
Employee ID_____ (Required) 1 2018 Benefits Program Qualifying Event Change Form Please Print - Please Complete ALL Applicable Sections If you have any questions, please contact the University of Rochester Benefits Office at (585) 275-8382 or
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