Employee Benefits Verification

EMPLOYEE BENEFITS VERIFICATION

Employer Information

Employee Personal Information

Employee Name:

Employee ID/Number:    Date of Birth:

Position Information

Original Hire Date:    Current Status Effective Date:

Benefits Enrollment Summary

Medical Plan Enrolled:    Plan Name:

Coverage Level:    Effective Date:    Termination Date (if any):

Dental Plan Enrolled:    Plan Name:

Vision Plan Enrolled:    Plan Name:

Life Insurance (Employer Provided):    Coverage Amount:

Short/Long Term Disability:    Plan Details:

Dependents Covered

List dependents covered under benefits (name, relationship, date of birth):

Premiums, Payroll and COBRA

Total Monthly Premium: $    Payroll Deduction Amount: $    Frequency:

COBRA Eligible:    Qualifying Event Date:    COBRA Notice Provided:

Termination or Leave Information (If Applicable)

Employment Status:    Last Day of Coverage:

Administrative Certification (To be completed by Employer/Benefits Administrator)

I certify under penalty of perjury that the information provided on this benefits verification is true, complete and accurate to the best of my knowledge. This verification is provided for the purpose of confirming benefits eligibility, coverage levels, premium contributions, and dates of coverage. The employer understands that third parties relying on this verification may do so in good faith and that the employer will notify requestors of material changes to coverage when known.

Employee Authorization and Release

I, the employee named above, hereby authorize my employer and its benefits administrator to disclose the information contained in this Benefits Verification to the requesting party for the purpose of validating coverage, calculating benefits, or verifying eligibility for benefits, loans, or services. I understand this authorization is limited to the information requested and does not authorize release of unrelated personnel records. I understand I may revoke this authorization in writing, except to the extent action has already been taken in reliance on this authorization.

Employment History (Required)

Provide two most recent employers. Include company, title, dates, primary responsibilities, and reason for leaving.

Title:    Dates Employed:

Title:    Dates Employed:

Education

Graduation Date:

Professional References

Provide three professional references.

Legal Disclosures

At-Will Employment: Employment, if applicable, is at-will except where otherwise provided by a written agreement executed by an authorized representative of the employer. Nothing in this form modifies or alters the at-will employment relationship.

Equal Employment Opportunity: The employer is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, or other protected status in any employment practice, including administration of benefits.

Applicant Certification and Authorizations

I certify that all information provided on this form is true and complete. I authorize the employer to verify any information contained in this form, to contact previous employers listed above, and to obtain records necessary to verify my benefits, employment history, or other details relevant to this verification. I understand that knowingly providing false information may be grounds for disciplinary action, up to and including termination.

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