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Flex125.com Phone: 888-868-3539 Fax: 609.257.0136 COBRA OPEN ENROLLMENT FORM Company Name: Date: Applicant Name: First Name SSN: MI Last Name Email: Address: City: Gender: M Zip+4: State: F DOB: Marital Status: Single Phone: Married HRA Enrolled: Applicant Coverage Coverage: Add Remove Decline Keep Same Plan Name: Medical Dental Vision RX Spouse Coverage Name: First Name MI Last Name Address (if different than Applicant): City: Coverage: Add Zip: State: Remove D.

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First: Its use is limited to specific merchants, based on the benefit account you have selected, and to those expenses that are deemed eligible by your plan. Second: You cannot use your AmeriFlex Convenience Card at an ATM or to obtain “cash back” when making a purchase.

Employers may make contributions to your FSA, but they aren't required to. With an FSA, you submit a claim to the FSA (through your employer) with proof of the medical expense and a statement that it hasn't been covered by your plan. Then, you'll get reimbursed for your costs.

Assuming one pays all required premiums, COBRA coverage starts on the date of the qualifying event, and the length of the period of COBRA coverage will depend on the type of qualifying event which caused the qualified beneficiary to lose group health plan coverage.

Once you've confirmed your FSA balance, you can spend every last dime on medical expenses, including health insurance deductibles and copayments (but not insurance premiums); prescription medications; over-the-counter medicines; and other supplies like crutches, blood test kits, and bandages.

You will receive an Ameriflex Debit Mastercard® linked to your account. You can use your card to pay for eligible expenses anywhere Mastercard® is accepted. To see what's eligible and learn more about your benefits, visit our Help Center. You will have easy and secure access to your account information, 24/7.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 requires employers with 20 or more employees who provide healthcare benefits to offer the option of continuing this coverage to individuals who would otherwise lose their benefits due to termination of employment.

COBRA coverage lets you pay to stay on your job-based health insurance for a limited time after your job ends (usually 18 months). You usually pay the full premium yourself, plus a small administrative fee. Contact your employer to learn about your COBRA options.

If employees spend more than they contribute, resulting in a net aggregate loss in the employer's plan, Ameriflex will refund the difference back to the employer.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232