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i <br /> NOTICE OF INTENT <br /> ~i TERMINATING REGULAR EMPLOYEES <br /> <br /> j From: Employee # Employee Signature Date <br /> i <br /> Check the appropriate line under each numbered heading and return form to your Office Manager or to HRRS. <br /> I <br /> t 1. HEALTH INSURANCE COVERAGE: (P/ease comp/ete the attached Notice of Qua/ifying Event form and return to <br /> your Office Manager, Supervisor or HRRS,) <br /> 2. PERS: <br /> ~ _ I am a PERS member and have considered the advantages/disadvantages of withdrawing funds from my PERS <br /> account. I understand that if I want to withdraw funds, I must contact a PERS office to receive the <br /> necessary withdrawal forms. (PERS Tigard headquarters toll-free: 1-888-320-7377) <br /> _ Not applicable since I am not a PERS member. <br /> I <br /> 3. DEFERRED COMPENSATION: <br /> I <br /> _ I have a deferred compensation account. I understand that I must contact my deferred comp carrier(s) for <br /> information on distribution and rollover options. <br /> Not applicable since I do not have a deferred compensation account. <br /> 4. LIFE INSURANCE: <br /> I want information on converting my City-paid group life insurance policy to an individual policy through <br /> Standard Insurance Company. <br /> I do not want to convert my group life insurance coverage to an individual policy. <br /> i <br /> 5. PORTABLE TERM SUPPLEMENTAL LIFE INSURANCE: <br /> _ I want to continue my Portable Life coverage through ReliaStar by paying the premiums directly to the carrier. <br /> I do not want to continue my Portable Life coverage. <br /> Not applicable since I do not have Portable Life coverage. <br /> 6. FLEXIBLE SPENDING MEDICAL ACCOUNT: <br /> _ I want to continue to contribute to my medical FSA after termination. <br /> I do not want to contribute to my medical FSA after termination. <br /> _ Not applicable since I do not have a medical FSA. <br /> <br />