Notification Of Employee Benefit Change Form - Archdiocese Of Louisville
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1ARCHDIOCESE OF LOUISVILLE
NOTIFICATION OF EMPLOYEE BENEFIT CHANGE
PARISH/ORGANIZATION_________________________________
Group # _________________
**SEND COMPLETED FORM TO PERSONNEL OFFICE**
Check Items to Change
EMPLOYEE DATA:
Employee Name______________________________________________________________
Street Address_______________________________________________________________
City/State/Zip________________________________________________________________
Phone: Home___________________Work___________________________
Social Security Number______________________
Annual Salary as of Jan. 1: $_________
Position___________________________________
Hours worked per week:____________
Employee Benefit Plans Affected:
Weeks worked per year:____________
Life Insurance
Hours worked per year:____________
Long-Term Disability
Single
E+1
Family
Health Insurance:
PreventivePlus
Humana PPO
Traditional Preferred
Dental Insurance:
EE
EE+CH
EE+SP
Family
Short-Term Disability
Health Care Spending Account $______
Dependent Care Spending Account $_______
**If change affects Flexible Spending Accounts, a copy of this form must be sent to AIM.
REASON FOR BENEFIT CHANGE:
TERMINATION DATE:_______________
Date Benefit Change Effective:_____________
Reason for Termination:_________________________________________________
Meets eligibility for Group 180, Early Retirees,
RETIREMENT DATE:___________________
AND elects coverage
TRANSFER DATE:_______________________ Date Benefit Change Effective:_____________
From Parish/Organization______________
Subgroup #:_______
To Parish/Organization________________
Subgroup #:_______
New Salary $____________
BENEFIT STATUS CHANGE:
Number of Hours Worked Weekly From________To________
Date Change Effective:_____________
New Salary $________________
Other:
Employee Signature___________________________________Date________________
Bookkeeper/Administrator_____________________________ Date________________
Revised 01/01/2016
Notification of Benefit Change Form.xls
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