Employment Verification Form Page 2
ADVERTISEMENT
1
2EMPLOYMENT VERIFICATION
LDSS-3707
(Rev. 4/01) REVERSE
PLEASE COMPLETE THE QUESTIONS BELOW WHICH ARE CHECKED (
):
1. Date Employment began:_______________________________
Rate of Pay______________________________
2. Date Employment ended:____________________________________________________________________________
Reason for termination _____________________________________________________________________________
________________________________________________________________________________________________
3. Does employee have life insurance through your company?
YES
NO
Or, through the union?
YES
NO
4. Does employee have health insurance through your company?
YES
NO
Or, through the union?
YES
NO
a. Is health insurance available to:
The employee?
YES
NO
The employee’s family?
YES
NO
b.
Is the employee and/or his/her family enrolled?
YES
NO
If yes, who is covered?
c. Name and address of Insurance Carrier
Effective date of coverage
Policy Number:
5. Does employee have disability benefits through your company?
YES
NO
Or through the union?
YES
NO
Name and address of Insurance Carrier________________________________________________________________
6. Does employee have payroll savings through your company?
YES
NO
If yes, please specify (i.e., bonds, credit union, IRA, deferred compensation, etc.):
_______________________________________________________________________________________________
7. To your knowledge, is the employee working anywhere else?
YES
NO
If yes, where:
_______________________________________________________________________________________________
8.
If this person has left your employ, did he/she indicate a new job?
YES
NO
If yes, where:
9. According to your records, what is employee’s address if different from the address on the reverse side
_______________________________________________________________________________________________
10. Is your company a temporary employment agency?
YES
NO
If yes, is the employee on-call? Please specify
______________________________________________________________________________________________
11. Other (Specified below):
REQUEST:
RESPONSE:
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Please print your name:____________________________________________________Date__________________________
Signature:_____________________________________________________________________________________________
Title:_________________________________________________________________________________________________
Telephone Number(________)________________________
PLEASE RETURN THIS FORM TO THE ADDRESS IN THE TOP LEFT CORNER OF THE OTHER SIDE OF THIS FORM
THANK YOU FOR YOUR COOPERATION
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal