Employer Forms

Enrollment Kit

 

Use the Enrollment Kit to enroll eligible employees.  The Enrollment Kit consists of three key items:

 

1.      Basic Plan Information and Enrollment Form;

2.      Investment Fund Information brochure; and

3.      Current Investment Fund Overview (updated quarterly).

 

These materials collectively provide newly enrolling employees with important plan details, including the available investment options.  Section 5: Employee Enrollment of your online employer handbook contains more information.

 

Enrollment Kits with a current Investment Fund Overview can be downloaded here.  A supply of hardcopies can be requested by contacting the plan consultant, VEBA Service Group, LLC.  In Western Washington, call 1-800-422-4023; in Eastern Washington and Idaho, call 1-800-888-VEBA (8322); in Oregon, call 1-877-695-3945.

 

NOTE:  When distributing Enrollment Kits to eligible employees, be sure to include the most recent Investment Fund Overview.  It is important that employees receive up-to-date investment performance when making their investment decisions.

 

pdf   HRA VEBA Enrollment Kit

 

 



Participant Status Change Form

 

Submit a Participant Status Change Form when a currently enrolled employee/participant:

 

1.       Is voluntarily or involuntarily terminated;

2.       Separates from service or retires;

3.       Experiences a reduction of hours; or

4.       Passes away.

 

Any of the above events may constitute a COBRA qualifying event if the employee/participant stops receiving employer contributions to which they or their qualified beneficiaries would have otherwise been entitled (e.g. ongoing monthly contributions).  To comply with federal COBRA requirements, employers must notify the third-party administrator (TPA) within 30 days when a COBRA qualifying event occurs.  Refer to Section 6.6: Employer COBRA Reporting Requirements in your online employer handbook for more details.

 

NOTE:  You DO NOT need to submit this form for employees who are becoming new HRA VEBA participants due to receipt of contributions at termination, separation from service, or retirement.  Report information for these employees on their Enrollment Forms.

 

pdf   Participant Status Change Form