Change of Status Form
GENERAL INFORMATION
Participant name:
Last four digits of Social Security #:
Employee ID:
Campus:
Effective date of change:  
If Leave of Absence, LoA return date:  
Final payroll end date:  
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:  
ORP Disability Conversion Notice:  
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: ( ) -
Additional comments (optional):