<p> Change of Status </p><p>Company Name: Employee Name: Change Date: Change Affects: o Employee o Spouse o Dependent Reasons for Change Request (check all that apply) Family Changes Event Date Employment Changes Event Date o Marriage o Job Termination o Divorce / Legal Separation o Job Commencement o Death of Dependent o Change to Full Time o Birth or Adoption o Change to Part Time o Court Ordered Dep. Coverage o Leave of Absence o Other: Please describe below o Other: Please describe below</p><p>Benefit Changes Event Date Describe Changes Marked “Other” Below: o Cost Increase o Benefit Decrease o Employer Cancellation o Other: Please describe at right</p><p>For Employer Use</p><p>Effective Date: Notes:</p><p>Approved By: Date Reviewed: For TPA Use</p><p>Effective Date (if approved): Notes:</p><p>Approved By: Date Reviewed: FAX TO: 501.687.3282 Or mail to: 1601 WestPark Drive Suite 9, Little Rock, AR 72204 </p>