Employment Verification Record Form
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2SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY
INSURANCE BENEFITS
EMPLOYMENT VERIFICATION RECORD
1. Social Security Number
2. Last Name
3. First Name
4. Home Phone #
5. Date of Birth
6. Type of Retirement:
Service Disability
(Attach Disability Approval Letter)
No
7. Did you participate in TERI?
8. Actual Date of Retirement
Yes – TERI End Date ____/____/_____
9. Name of Current Employer
Dates of Employment
Status
Service Credit
(Example: Jan 2009 to Mar 2011)
(Years & Months)
Full-time
Part-time
_____ Yrs _____ Mos
10. List previous employment with employers participating in one of the retirement systems administered by
the S.C. Public Employee Benefit Authority and/or with Local Subdivisions participating in PEBA Insurance Benefits
Dates of Employment
Service Credit
Name of Employer
Status
(Example: Jan 2009 to Mar 2011)
(Years & Months)
Full-time
_____ Yrs _____ Mos
Part-time
Full-time
_____ Yrs _____ Mos
Part-time
Full-time
_____ Yrs _____ Mos
Part-time
Full-time
_____ Yrs _____ Mos
Part-time
Full-time
_____ Yrs _____ Mos
Part-time
Full-time
_____ Yrs _____ Mos
Part-time
Full-time
_____ Yrs _____ Mos
Part-time
11. Do you have any additional service time established with one of the
Yes (List Total Years & Months)
retirement systems administered by the S.C. Public Employee Benefit
_____ Yrs _____ Mos
No
Authority?
(Ex. Purchased time, military, out-of-state, etc.)
12. Total Years of Service Credit
_____ Yrs _____ Mos
If you are a member of one of the defined benefit plans administered by the S.C. Public Employee Benefit Authority, PEBA Insurance
Benefits will review your service records to determine eligibility for retiree insurance. Please check all that apply:
South Carolina Retirement System
Judges and Solicitors Retirement System
Police Officers Retirement System
General Assembly Retirement System
This section should only be completed if you are a State ORP participant or the employee of an employer that does not
participate in one of the retirement systems administered by the S.C. Public Employee Benefit Authority
If you are a participant of the State Optional Retirement Program (State ORP) or an employee of an employer that does not
participate in one of the retirement systems administered by the S.C. Public Employee Benefit Authority, your benefits administrator
must verify your employment history with his employer only and sign the verification record. By signing below, you certify the
information provided is complete and accurate.
State Optional Retirement Program (State ORP)
Employer does not participate in one of the retirement systems
administered by the S.C. Public Employee Benefit Authority
Service Credit
_____ Yrs _____ Mos
Benefits Administrator Signature __________________________________________ Date _________________
Enrollee Signature _____________________________________________________ Date _________________
02/2013
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