NCFlex Transfer Request Form

NCFlex Transfer Request Form

This form is intended to notify NCFlex and in turn, Benefitfocus when an employee is transferring from a USO employer to a Non-USO employer and benefits need to be transferred from Empyrean to Benefitfocus.

Name Of Health Benefit Representative or NCFlex Rep*

E-mail Address*

HBR Phone Number*

Giving Employer*

What employer is the employee coming from?

Select or enter value

Separation date

Receiving Employer

What employer is the employee coming to?

Select or enter value

Start Date

Last Four Digits of SSN*

Last four digits of Employee's SSN number

Please do not include full SSNs on this form.

Employee's Full Name*

As listed in the enrollment system.

Employee ID#

Not SSN

University Benefits (if known)

Cancer and/or Critical Illness

Coverage level and who was covered

Dependent(s) Name*

Please have employee add dependent(s) in the enrollment platform with valid SSN and DOB prior to submitting this form (don't include SSN or DOB on this form). If they are not able to add dependents themselves, they can call the enrollment support line at 1-855-859-0966. If no dependents are being requested on the plan(s), put N/A.

Does a gap in coverage need to be bridged?

Attach documentation

Provide any documentation that may assist with the decision.

Drag and drop files here or

Send me a copy of my responses

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