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Change of Status Form |
| GENERAL INFORMATION |
| Participant name: |
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| Last four digits of Social Security #: |
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| Employee ID: |
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| Campus: |
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| Effective date of change: |
,
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| If Leave of Absence, LoA return date: |
,
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| Final payroll end date: |
, |
| Comments: |
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| REASON FOR STATUS CHANGE |
Termination
Deferred Retirement
Leave of Absence
Retiree
Non-Benefited
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Reduced Hours
Military Leave
Non-ORP Position
Return from LOA
Other:
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| If Termination, Deferred Retirement, or Retiree, select one: |
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Participant will receive their balance of contract payments (paid for 12 months)
Participant will be paid the balance of their contract as a lump sum at the time of their termination/retirement
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| In cases where a participant chooses to be "paid off" at the time of their termination or retirement, instead of being paid the balance of their contract for the remainder of a 12-month period, then you must provide the following information to ensure the Plan Administrator credits the participant with Months of Participation under the ORP for the remaining pay periods comprising the balance of their contract: |
| Pay Period End Date of the payment of their lump sum: |
,
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| Complete the chart below:
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| STANDARD INSURANCE CONVERSION NOTICES |
| Notice |
Date Provided |
| ORP Group Life Conversion Notice: |
,
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| ORP Disability Conversion Notice: |
,
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| GIC REPORTING |
| I have completed GIC Form 1 for this participant: |
Yes
No
N/A |
| The participant will be a: |
Deferred Retiree
Retiree |
| BENEFITS ADMINISTRATOR INFORMATION |
| Administrator Name: |
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Email:
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| Please make sure the above email address is correct. A confirmation notice and additional instructions will be emailed to this address. |
| Telephone: |
(
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| Additional comments (optional): |
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| CONFIRMATION (spam prevention) |
| Confirmation code: |
 Change code |
| Enter above code: |
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| If you have problems submitting this form, contact webmaster@dhe.mass.edu. |