"Employee Change of Status Form"

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Change of Status Form
EMPLOYEE INFORMATION
Payroll Company/Work Location
Date of Hire
Social Security Number
Last Name
First Name
Middle
Address
City, State
Zip Code
Marital Status
Date of Birth
Sex
Phone Number
Married
Single
Health
Add
Drop
Office use only:
Date: ____________________
Employee
By: ______________________
Dependent(s)
Dental
Add
Drop
Office use only:
Change Plan
Basic
Employee
Date: ____________________
Buy- up
Dependent(s)
By: ______________________
Vision
Add
Drop
Office use only:
Change Plan
Date: ____________________
Employee
Basic
Dependent(s)
Buy- up
By: ______________________
Disability:
Office use only:
Add
Drop
Short Term
Date: ____________________
By: ______________________
Disability:
Add
Drop
Office use only:
Long Term
Date: ____________________
Drop=due to LTD claim approval
By: ______________________
Voluntary
Add
Increase
Decrease
Drop
Office use only:
Life:
Employee $__________________
Date: ____________________
Spouse
$__________________
Basic Life
Child
$__________________
By: ______________________
8/16/14-alg
Change of Status Form
EMPLOYEE INFORMATION
Payroll Company/Work Location
Date of Hire
Social Security Number
Last Name
First Name
Middle
Address
City, State
Zip Code
Marital Status
Date of Birth
Sex
Phone Number
Married
Single
Health
Add
Drop
Office use only:
Date: ____________________
Employee
By: ______________________
Dependent(s)
Dental
Add
Drop
Office use only:
Change Plan
Basic
Employee
Date: ____________________
Buy- up
Dependent(s)
By: ______________________
Vision
Add
Drop
Office use only:
Change Plan
Date: ____________________
Employee
Basic
Dependent(s)
Buy- up
By: ______________________
Disability:
Office use only:
Add
Drop
Short Term
Date: ____________________
By: ______________________
Disability:
Add
Drop
Office use only:
Long Term
Date: ____________________
Drop=due to LTD claim approval
By: ______________________
Voluntary
Add
Increase
Decrease
Drop
Office use only:
Life:
Employee $__________________
Date: ____________________
Spouse
$__________________
Basic Life
Child
$__________________
By: ______________________
8/16/14-alg
PLEASE LIST ONLY THE DEPENDENTS THAT ARE BEING ADDED OR DROPPED:
Full Name
Relationship
Sex
Date of birth
Soc Sec #
Applies to?
Health
Dental
Vision
Vol Life
Health
Dental
Vision
Vol life
Health
Dental
Vision
Vol life
Health
Dental
Vision
Vol life
I hereby certify that all information provided in this Enrollment Form is complete and accurate.
I understand that any misrepresentation of information will be used by my employer to reduce or deny
a claim for benefits as well as result in disciplinary and possible legal action.
I am applying/dropping the coverage(s) shown above, and authorize my employer to payroll
deduct the premiums due for said coverage(s) from my payroll checks. I wish these plan selection(s) to
be deducted on a pre-tax basis under cafeteria plan guidelines where appropriate, understanding that
these deductions will reduce my taxable compensation. I understand that I cannot make changes to
these deductions except in the case of a qualifying event (i.e. death, divorce, birth of child).
Employee Signature:
Date:
TO BE COMPLETED BY BENEFITS ADMINISTRATOR ONLY
Reason
Date
Termination of Employment
Coverage Effective Date:
Open Enrollment
____________________________________
Marriage
Divorce
Last Day Worked: ____________________
Birth/Adoption
Termination Date:_____________________
Death
Transfer From_________ To___________
Coverage Termination Date:
Other (specify) ______________________
_____________________________________
Hours worked &
income details
BA Signature
Date
7/2/14-alg
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