Status Change Request Form PARTICIPANT INFORMATION Participant Name: Employer Name: Employee ID: Participant Email:  REPLACE EXISTING ELECTION Existing Election Amount: Deduction per Pay Period: New Election Amount: Deduction per Pay Period: Date Changes will be Effective: First payroll date after Effective:  ADD NEW ELECTION (Enrollment Form must also be submitted) Date Effective: First payroll date after Effective: Last payroll date after Effective:  TERMINATION (last date of benefits coverage) Date Effective:  Yes If Yes,  No Effective Date:  CHANGE IN DEPENDENT STATUS Relationship Last Name First Name to Employee COBRA Elected? Termination Date: (last day of coverage) Social Security Number* Date of Birth* Add or Term Gender Date  OTHER Explain: Please print this form, sign, and return to your employer for processing. Employee Signature: Date: Employer Signature: Date: * Social Security and date of birth for employees and their dependents are required for HRA reporting purposes to the Centers for Medicare and Medicaid Services as part of the Medicare, Medicaid, and SCHIP Extension Act of 2007. Change Forms without this required information will be returned for completion. Total Administrative Services Corporation (TASC) | P.O. Box 7511 | Madison, WI 53707‐7511 Phone: 877‐933‐3539 | Fax: 877‐231‐1287 TC‐5545‐010116