Addition & Rehire and Status Change From

ADDITION, REHIRE and

STATUS CHANGE FORM

This form must be completed by the employer each time a participant is added or a status change occurs to ensure proper administration of the Plans. Please complete the required information below and submit to Genesis Employee Benefits via upload to the Secure Portal, email, fax or mail.
If it is more convenient, due to a large volume of participants being added or having status changes, you may submit this information by electronic file. The file needs to include the appropriate fields for each of the items below. Please contact us for more information about using this electronic file method of transmitting the status change data.
Employer: / Division, if applicable:
Employee Name: / Name Change
Social Security Number: / -- / Employee Phone #: --
Home Address:
City, State, Zip: / Address Change
Email Address:
Hire Date: / Birth Date:
VEBA/115 and RMSA Plans – Please check ALL that apply
1. Adding New Participant Effective date: VEBA/115 RMSA
Is this participant claim active? clickYesNo Date of first employer contribution to account:
2. Rehire of Former Participant VEBA/115 RMSA
Rehire date: Effective date of participation:
3. Termination of Employment
Last day of employment: Loss of coverage date:
This terminated participant will be receiving additional employer contributions to the VEBA/115,
Date the participant’s last contribution will be deposited:
4. Retirement
Date of retirement: Loss of coverage date:
Change ofVEBA/115 claim status clickNon-Claim Active to Claim ActiveClaim Active to Non-Claim ActiveActive Employee no Future ContributionsEffective date of claim status change:
This retired participant will be receiving additional employer contributions to the VEBA/115.
Date the participant’s last contribution will be deposited:
5. Death of Participant
Date of death:
Surviving spouse? clickYesNo If yes, please provide name and SSN of spouse:
If no spouse, are there any dependents? clickYesNo Name and SSN of youngest dependent:
FSA, HRA, RMA, and 105 Plans
* Participants that are new, re-hires, or have a qualified change in status must complete an Enrollment Form
1. Adding New Participant* Effective date: First date of payroll reductions:
2. Rehire of Former FSA, HRA, RMA, or 105 Plan Participant*
Rehire date: First date of payroll reductions:
3. Termination of Employment or Retirement
Last day of employment: Last date of payroll reductions:
4. Qualified Change in Status* Effective date of qualified change in status:
Choose One: Birth/Adoption Marriage Divorce Leave of Absence Death of Participant
Death of Spouse/Dependent Job Change Spouse Job Change Return from Leave of Absence
Name of person submitting this change:

UPLOAD completed forms to: Genesis SecurePortal

Secure eFax: 952-460-1480 / / Toll-Free Phone: 866-678-8322

Genesis Employee Benefits, Inc.

12Addition-Rehire-and-Status-Change-Form-(Fill-In).doc6/5/2012