Vital Information - Survivor'S Benefit Checklist Page 7
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12Vital Information
(Fill out and store in a safe location. This information should be updated periodically.)
PERSONAL INFORMATION
Full Legal Name:
Date of Birth:
Social Security Number:
EMPLOYMENT INFORMATION
Employer (Agency or Department):
Employer Address:
Phone Number:
Employee E-mail Address:
Date of Hire:
Supervisor's Name:
Supervisor's Phone Number:
Supervisor's E-mail Address:
Personnel Office Address:
Personnel Office Phone Number:
Personnel Office E-mail Address:
Employee Organization/Association Name:
Employee Organization/Association Unit Number:
Check One:
Non-Represented
Exempt
Excluded
Confidential
PERS Member:
Type:
Yes
No
Tier 1
Tier 2
EMPLOYER BENEFITS
Pre-Tax Parking
Check Benefits Programs you are enrolled in:
Consolidated Benefits (CoBen)
Savings Plus Program
Flex Program
State Sponsored Insurance Plan
Legal Services Plan
Travel and Accidental Death Insurance
Long-Term Care
Union Sponsored Life Insurance Plan
Long-Term Disability Program
Vision Plan
PST Retirement Program
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Related forms
Form Ee-2 - Survivor's Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - United States Department Of Labor, Office Of Workers' Compensation Programs
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Related Categories
Parent category: Legal