Terminations / Changes

If you are a COBRA Client, please visit our COBRA Terminations page.

It is very critical that we receive up to date information regarding participants enrolled in the Health Reimbursement Arrangement (HRA), Flexible Spending Account (FSA), Dependent Care Account (DCA) and the Transit Reimbursement Account (TRN).

Terminated Employee

Your Name *

First

Last

Company Name *

Phone Number *

Email *

Employee Name *

What plan(s) was the Employee enrolled in? *

HRA FSA DCA TRN

Last Date Worked *

Last Payroll Date *

If the Employee's last payroll date was not the last payroll date of the month, will the final check include the full months payroll deduction(s)? *

Yes No N/A

According to your records, how much has the employee contributed to the plan once their final paycheck is issued? *

Submit