Change to Ineligible Position
To be completed by Benefits Administrator
GENERAL INFORMATION
Participant Name:
Social Security #: - -
Effective Date of Change:  
Institution/Campus:
Comments:
 
CONTROL DATES
Form/Task Date Provided to Employee
ORP Group Life Conversion Notice:  
 
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: ( ) -