Welcome to United Agencies Inc.

QUALIFYING EVENT FORM

NAME OF EMPLOYER
Name of Person Submitting this Form
Email Address of Person Submitting Form
Employee First Name
Last Name
Home Address
City
State
Zip
Social Security #
Date of Birth
Date of Hire
Date Coverage FIRST Effective
Date of Qualifying Event
Type of Qualifying Event:	Involuntary Termination Voluntary Resignation Reduction of Work Hours Employee Death Divorce or Legal Separation Loss of Dependent Status Medicare Entitlement Retirement
Send Notice in	English Spanish
Name of Medical Plan Enrolled In? (HMO, PPO, etc.)
Type of Medical Coverage:	Employee Only EE & Spouse EE & Children Family WAIVED
Monthly Medical Premium
Name of Dental Plan Enrolled In? (HMO, PPO, etc.)
Type of Dental Coverage:	Employee Only EE & Spouse EE & Children Family WAIVED
Monthly Dental Premium
Name of any other plan? (Vision, Chiropractic, etc.)
Type of Other Coverage:	Employee Only EE & Spouse EE & Children Family WAIVED
Other Plan Monthly Premium
Flexible Spending Account - Monthly Contribution Amount:
Spouse Name (Full Name)
Full Names of any Children
Alternative Address for Dependents