Employee IMRF Form

EMPLOYEE IMRF FORM

Employee Information

Employee Name:   Date of Birth:

Phone:   Email:

Position and IMRF Membership Details

Reporting Manager:   Date of Hire (MM/DD/YYYY):

Employment Status: Full-Time Part-Time Temporary

IMRF Membership Election: Enroll in IMRF effective with date of hire Defer membership (employer to retain records)

Employer Certification (for employer use)

Employer ID/Unit Code:   Payroll Frequency:

Beneficiary Designation

Designate primary and contingent beneficiaries for IMRF death benefits. Percentages must total 100% for each beneficiary class.

Relationship:   DOB:   Share %:

Relationship:   DOB:   Share %:

Prior Public Service and IMRF Membership

Have you previously been a member of IMRF or another public retirement system?   Yes No

Employment History

Provide two most recent employers for background and service verification.

Title:   From:   To:

Title:   From:   To:

Education

Graduation Date:

References (Professional)

Provide three professional references.

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Legal Disclosures & Authorizations

At-Will Employment: Employment with this employer, unless governed by a binding collective-bargaining agreement or written contract, is at-will. Either the employee or the employer may terminate the employment relationship at any time, for any lawful reason, with or without cause and with or without notice.

Equal Opportunity: The employer is an equal opportunity employer. No person shall be discriminated against in employment because of race, color, religion, national origin, sex, age, disability, or any other characteristic protected by law.

Authorization to Verify Information: I authorize the employer, IMRF, and their agents to verify any information provided on this form, including prior employment and membership in public retirement systems, and to obtain such records as are necessary to establish IMRF membership and service credit. I release all previous employers and other providers of information from liability for disclosure of such information to the employer or IMRF.

Contributions and Deduction Acknowledgment: I acknowledge that applicable employee pension contributions required by IMRF will be deducted from my wages in accordance with statutory rates and that such contributions are subject to the rules, terms, and conditions of IMRF. I understand that refunds of contributions, purchase of prior service, or other remedies are governed by IMRF policy and statute.

Reciprocity and Prior Service: If I assert reciprocity or request credit for prior public service, I agree to provide satisfactory documentary evidence and understand that final determinations of credit and reciprocity are made by IMRF in accordance with applicable statutes and rules.

Applicant Certification and Authorization

I certify that all information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may subject me to disciplinary action, including denial of membership, forfeiture of benefits, or termination of employment in accordance with employer policy and applicable law.

I authorize the employer and IMRF to obtain my employment records, earnings records, and any prior public employment or retirement records necessary to establish membership, compute service credit, and determine eligibility for benefits. I understand that this authorization shall remain in effect until revoked in writing to the employer and IMRF, but such revocation will not affect any action taken in reliance on this authorization prior to receipt of the revocation.

Applicant acknowledges that enrollment in IMRF and all determinations concerning membership, contributions, refunds, and benefits are subject to IMRF governing statutes, rules, and administrative decisions. This form is a record of the employee's election and authorizations and may be relied upon by the employer and IMRF.

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