Home
Products / Services
Cafeteria Plan (FSA, DCAP, TRN & POP)
>
Discrimination Testing
FSA Eligible Expenses
Videos
Health Reimbursement Arrangement (HRA)
Health Savings Account (HSA)
COBRA Administration
>
Medicare & COBRA
Videos
Dental
Life / Disability
Vision
Healthcare Reform Services
Forms
Clients / Participants
COBRA Clients
FAQ
>
Cafeteria Plan FAQ
COBRA FAQ
Find A Provider
>
Dental - Oregon & SW Washington
Dental - Throughout the US
Vision
FSA Eligible Expenses
Login
Terminations / Changes
Reimbursement Request
Benefit Card Transaction Submission
Videos
News & Events
Facebook
Social Media
Contact Us
Career Opportunities
Feedback
>
Broker Feedback
Client / Participant Feedback
Secure Email
Quote Request
What Can We Do For You?
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
Please select N/A if the participant was only enrolled in an HRA.
According to your records, how much has the employee contributed to the plan once their final paycheck is issued?
*
Please fill out N/A if the participant was only enrolled in an HRA.
Submit