Change of Status Form
GENERAL INFORMATION
Participant name:
Social Security #:
-
-
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 University
Fitchburg State University
Framingham State University
Massachusetts College of Art and Design
Massachusetts College of Liberal Arts
Massachusetts Maritime Academy
Salem State University
Westfield State University
Worcester State University
--
University of Massachusetts Amherst
University of Massachusetts Boston
University of Massachusetts Dartmouth
University of Massachusetts Lowell
University of Massachusetts Worcester
University of Massachusetts President
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
,
2013
2014
2015
If Leave of Absence, LoA return date:
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
,
2013
2014
2015
Final payroll end date:
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
,
2013
2014
2015
Comments:
REASON FOR STATUS CHANGE
Termination
Deferred Retirement
Leave of Absence
Retiree
Non-Benefited
Reduced Hours
Military Leave
Non-ORP Position
Return from LOA
Other:
STANDARD INSURANCE CONVERSION NOTICES
Notice
Date Provided
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
,
2013
2014
2015
ORP Disability 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
,
2013
2014
2015
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:
Email:
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):