Employer Forms

Coverage Options Model Notice for Employers Who Offer a Health Plan
Employers covered by the Fair Labor Standards Act are required to provide a notice to employees about the health insurance marketplace/exchanges of the state(s) in which they operate.

Employee Change/Termination Form
This form is used to notify Significa Benefit Services of a termination of benefits or a change in an employee's status. Examples of this are: Class or Position Change, Beneficiary Change, Name or Address Change, Notice of a Rehire (enrollment may be required), Leave of Absence, Salary Change, and Termination of Employment.

Employer Eligibility Verification
This form is completed by the employer to confirm eligibility of the employee (for example to determine they are working the number of hours to be eligible for coverage, or if on a leave that the leave is being administered in accordance with the leave provisions in the plan document.) When the employee or their covered dependent or spouse incurs claims that reach the individual stop loss threshold, this information is required.

Employer Statement Form
This form is used to verify information for disability claims.

Flexible Spending Account Change of Status Form
This form is used to add a dependent or revise an employee's pledge amount. Do not use this form to terminate FSA benefits. See Flexible Spending Account Termination Form.

third party administrator employer forms

Election Form and Compensation Reduction Agreement
This form is used to enroll employees for Flexible Spending Account benefits. Important note to employers with option for direct deposit: Contact Client Services for the correct enrollment form.

Flexible Spending Account Termination Form
This form is used to terminate an employee's participation in a Flexible Spending Account.

Health Reimbursement Arrangement Employer Application
This form is used to implement a new Health Reimbursement Arrangement Plan for an employer.

Sample EOB
This is a sample Explanation of Benefits (EOB) form.

SBC Uniform Glossary
This is a uniform glossary of terms commonly used in health insurance coverage.

Code Section 213(d) Eligible Expenses
This is a listing of common IRS Section 213(d) eligible reimbursable expenses.

Self-funded Employee Enrollment Form
This form is used to enroll employees and dependents for medical, dental, vision, life and STD.