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Health FSA
Participant Termination Form
This form is to be completed when an employee terminates or loses eligibility in the health FSA. A participant who loses
coverage under the health FSA component
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How to fill out health fsa participant termination
How to fill out health fsa participant termination
01
Obtain the Health FSA Participant Termination form from your employer or benefits administrator.
02
Fill out your personal information, including your name, employee ID, and contact details.
03
Indicate the reason for termination and the effective date.
04
Review the form to ensure all information is accurate and complete.
05
Sign and date the form.
06
Submit the completed form to your employer or benefits administrator.
Who needs health fsa participant termination?
01
Employees who wish to terminate their participation in a Health FSA (Flexible Spending Account) need to fill out the Health FSA Participant Termination form.
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