Employee Election Form (POP and Flex Plans)

NOTICE NOTICE NOTICE

Please note the following changes have been made to your Section 125 Cafeteria Plan effective 1/1/2008

NEW WEB ADDRESS: www.ezflexplan.com/bcbsla

Note: The previous website of www.ezflexplan.com/snl will remain active for a 90 day transition period.

FORMS: Please begin to use the attached forms for administration of your 125 plan. The forms include:

- Employee Election Form (POP and Flex Plans)

Flex Plan Forms

- Change in Status/ Election Termination Form

- Claim for Flex Plan Reimbursement

- Dependent Care Services (Daycare Flex)

- Employee COBRA Notice and Election Form

The forms will also be available on the above website. The changes made will not effect the day to day administration of your Section 125 Plan.

If you have any questions or concerns please feel free to contact our office.

Thank you.

Blue Cross Blue Shield of Louisiana

Section 125 Cafeteria Plan

P.O. Box 98025 Baton Rouge, LA 70898

1-800-376-7734 225-298-3105