Employee Eligibility Form

Please complete this form for New Hires, Qualifying Event Changes, and Terminations

Company Name

Employee Name

Employee Email Address

Job Title

Required if Company offers LTD or STD

Salary

Required if Company offers LTD, STD, or Life Benefits based on income

Location/Division

Please specify campus/out-of-state/etc., if applicable

Type of Enrollment/Termination

Please select Qualifying Event for Dependent Changes

Hire Date

Date the Employee became Eligible (Full-time Hire Date)

Notes

Submitted By Name

Company Contact Email Address

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