Change to Ineligible Position
To be completed by Benefits Administrator
GENERAL INFORMATION
Participant Name:
Social Security #:
-
-
Effective Date of Change:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
,
2010
2011
2012
Institution/Campus:
Berkshire Community College
Bristol Community College
Bunker Hill Community College
Cape Cod Community College
Greenfield Community College
Holyoke Community College
Massachusetts Bay Community College
Massasoit Community College
Middlesex Community College
Mount Wachusett Community College
North Shore Community College
Northern Essex Community College
Quinsigamond Community College
Roxbury Community College
Springfield Technical Community College
--
Bridgewater State College
Fitchburg State College
Framingham State College
Massachusetts College of Art
Massachusetts College of Liberal Arts
Massachusetts Maritime Academy
Salem State College
Westfield State College
Worcester State College
--
University of Massachusetts Amherst
University of Massachusetts Boston
University of Massachusetts Dartmouth
University of Massachusetts Lowell
University of Massachusetts Worcester
University of Massachusetts President
Comments:
CONTROL DATES
Form/Task
Date Provided to Employee
ORP Group Life Conversion Notice:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
,
2010
2011
2012
BENEFITS ADMINISTRATOR INFORMATION
Administrator Name:
Email:
Please make sure the above email address is correct.
A confirmation notice and additional instructions will be emailed to this address.
Telephone:
(
)
-