Employee Change Of Status Form
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1
2E
C
S
F
MPLOYEE
HANGE OF
TATUS
ORM
Fill out a separate Change of Status Form for each benefit election change requested.
EMPLOYER NAME____________________________________
D
: ________________
ATE
E
N
: ___________________________________________________________________________
MPLOYEE
AME
SSN: ______________________________________
D
: ____________________________________
IVISION
: Before submitting this form, check the Change of Status matrix distributed with the Summary Plan Description
P
LEASE READ
to see if the change in election you are requesting is acceptable for your change in status. You must submit a Change of Status
Form within 30 days of the changing event.
I want to replace an existing election with a new election effective on pay period ___________
.
EFFECTIVE DATE CANNOT BE BEFORE THE LATER OF DATE OF EVENT OR THE DATE FORM IS SIGNED AND RECEIVED BY PLAN ADMINISTRATOR
Existing Benefit Election: _________________________________________
Deduction Amount per Pay Period: $ ______________________
New Benefit Election: ____________________________________________
.
Deduction Amount per Pay Period: $ ______________________
My event is: ____________________________________________________________________________
________
_____________________________________________ Event Date: _______________ Code
effective on pay period: ___________________________
I want to
ADD A NEW ELECTION
effective on pay period: ________________________
TERMINATE AN ELECTION
.
EFFECTIVE DATE CANNOT BE BEFORE THE LATER OF DATE OF EVENT OR THE DATE FORM IS SIGNED AND RECEIVED BY PLAN ADMINISTRATOR
Deduction Amount per Pay Period: $ ______________________
Benefit Election: ________________________________________________
My event is: _____________________________________________________________________
_____________________________________________ Event Date: _______________ Code _________
I certify that I have had the above change in status and request that changes in my elections be made as indicated.
In no event may the actions be effective before the first pay period beginning after this form is completed and
returned to MY EMPLOYER.
Employee Signature: _________________________________________
Date: ___________________
EMPLOYER A
C
R
CCEPTANCE OF
HANGE
EQUEST
(C
PAYROLL DEPT.
)
OMPLETED BY
AS AUTHORIZED
Change in deductions made on Pay Period No. _____________ Pay Date: ___________________________
Authorized Signature: __________________________________________
Date: ___________________
SHAFFER INSURANCE SERVICES INC. C
E
R
HANGE
NTRY
ECORD
Change in deductions made on Pay Period No. _______ Pay Date: __________
Signed: ______________________________________________________
Date: ___________________
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