"Employee Work Status Action Form for Public Employees Local 71 Trust Fund Members" - Alaska

Employee Work Status Action Form for Public Employees Local 71 Trust Fund Members is a legal document that was released by the Alaska Department of Administration - a government authority operating within Alaska.

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Download "Employee Work Status Action Form for Public Employees Local 71 Trust Fund Members" - Alaska

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EMPLOYEE WORK STATUS ACTION FORM
For Public Employees Local 71 Trust Fund Members
ADDRESS: 111 West Cataldo Ave. #220, Spokane, WA 99201 TOLL FREE PHONE: 800-557-8701, option 2, then 2
FAX: 509-534-5910 EMAIL:
ZA-SPO-PE71@zenith-american.com
and
tracy@local71.com
USE THIS FORM to notify the PE Local 71 Trust Fund
NEW HIRES: When the Trust receives this completed form,
Administrator if you are a new hire or if you are a current
you will be mailed a Health & Voluntary Benefits Enrollment
employee with a work-status change.
Packet.
1.
Complete this form immediately, when you are
Complete and return the New Hire enrollment
hired or have a work-status change.
forms within 30 days of the date listed on your PE71
2.
You then mail, email or fax the completed form to
Trust Fund-New Hire “Welcome” Letter.
the PE Local 71 Trust Fund (see above).
If you do not turn in the New Hire enrollment forms
3.
You will receive additional information in the mail. It
within the deadline, you will:
is in your best interest to ensure the Trust is
o
Full-Time: “Default” into the Trust’s
provided a good mailing address for you, at all
Yellow Family Plan with NO Voluntary
times.
benefits.
o
Part-Time: You will not have Health or
Voluntary benefits.
It is YOUR responsibility (not your employer’s or the union’s) to personally contact the PE71 Trust to:
Enroll in health benefit and/or voluntary benefits within the allotted time as a new hire or for a work-status change.
Continue health coverage when your active health coverage ends.
PLEASE PRINT CLEARLY
Employee Name:
Birthdate:
Gender:  M
 F
SSN:
Work Phone:
Cell Phone:
Email:
Home Phone:
Mailing Address:
Is this a new address?  Yes
 No
City/State/Zip:
SELECT THE FOLLOWING CATEGORY THAT DESCRIBES YOU
FULL-TIME working 30+ hours weekly
PART-TIME working 15-29 hours weekly
 Permanent Full-Time
 Permanent Part-Time
 Permanent Seasonal
 Nonpermanent Part-Time (ineligible for health or
 Nonpermanent (ineligible for health or voluntary insurance
voluntary insurance
SELECT THE “WORK STATUS” ACTION THAT APPLIES TO YOU
 New Hire / Hire Date: __________________________
 Work status change (select one )
 Full-Time to Part-Time
 Return to work
 Part-Time to Full-Time
 Transfer from another bargaining
Effective Date: __________________
unit to PE71
 Termination, leave, layoff or transfer
 SLWOP (Seasonal Leave Without
 Layoff
(select one )
 FMLA (Family or Medical Leave)
Pay)
 LWOP (Leave Without Pay)
 Separation from employment
Last day worked: _________________
 Going to On-Call
 Other: ____________________
 Transfer from PE71 to another
bargaining unit
EMPLOYEE SIGNATURE
Sign Here:
Date:
Your signature verifies that the information you have provided is correct and that you understand it is YOUR responsibility to
contact Public Employees Local 71 Trust Fund regarding your health and voluntary benefits.
Check the following box if you would like the Trust to share this information with the Union. 
EMPLOYEE WORK STATUS ACTION FORM
For Public Employees Local 71 Trust Fund Members
ADDRESS: 111 West Cataldo Ave. #220, Spokane, WA 99201 TOLL FREE PHONE: 800-557-8701, option 2, then 2
FAX: 509-534-5910 EMAIL:
ZA-SPO-PE71@zenith-american.com
and
tracy@local71.com
USE THIS FORM to notify the PE Local 71 Trust Fund
NEW HIRES: When the Trust receives this completed form,
Administrator if you are a new hire or if you are a current
you will be mailed a Health & Voluntary Benefits Enrollment
employee with a work-status change.
Packet.
1.
Complete this form immediately, when you are
Complete and return the New Hire enrollment
hired or have a work-status change.
forms within 30 days of the date listed on your PE71
2.
You then mail, email or fax the completed form to
Trust Fund-New Hire “Welcome” Letter.
the PE Local 71 Trust Fund (see above).
If you do not turn in the New Hire enrollment forms
3.
You will receive additional information in the mail. It
within the deadline, you will:
is in your best interest to ensure the Trust is
o
Full-Time: “Default” into the Trust’s
provided a good mailing address for you, at all
Yellow Family Plan with NO Voluntary
times.
benefits.
o
Part-Time: You will not have Health or
Voluntary benefits.
It is YOUR responsibility (not your employer’s or the union’s) to personally contact the PE71 Trust to:
Enroll in health benefit and/or voluntary benefits within the allotted time as a new hire or for a work-status change.
Continue health coverage when your active health coverage ends.
PLEASE PRINT CLEARLY
Employee Name:
Birthdate:
Gender:  M
 F
SSN:
Work Phone:
Cell Phone:
Email:
Home Phone:
Mailing Address:
Is this a new address?  Yes
 No
City/State/Zip:
SELECT THE FOLLOWING CATEGORY THAT DESCRIBES YOU
FULL-TIME working 30+ hours weekly
PART-TIME working 15-29 hours weekly
 Permanent Full-Time
 Permanent Part-Time
 Permanent Seasonal
 Nonpermanent Part-Time (ineligible for health or
 Nonpermanent (ineligible for health or voluntary insurance
voluntary insurance
SELECT THE “WORK STATUS” ACTION THAT APPLIES TO YOU
 New Hire / Hire Date: __________________________
 Work status change (select one )
 Full-Time to Part-Time
 Return to work
 Part-Time to Full-Time
 Transfer from another bargaining
Effective Date: __________________
unit to PE71
 Termination, leave, layoff or transfer
 SLWOP (Seasonal Leave Without
 Layoff
(select one )
 FMLA (Family or Medical Leave)
Pay)
 LWOP (Leave Without Pay)
 Separation from employment
Last day worked: _________________
 Going to On-Call
 Other: ____________________
 Transfer from PE71 to another
bargaining unit
EMPLOYEE SIGNATURE
Sign Here:
Date:
Your signature verifies that the information you have provided is correct and that you understand it is YOUR responsibility to
contact Public Employees Local 71 Trust Fund regarding your health and voluntary benefits.
Check the following box if you would like the Trust to share this information with the Union. 