Transcription of Standard Response to Verification of Employment
1 Standard Response to Verification of EmploymentEmployers will provide requested information normally maintained on employees. If additional information not listed on this form is needed, please contact the SECTION - Employee Personal InformationFull Address, if known:Street AddressApartment/Unit #CityStateZIP CodeMailing Address, if known:Street AddressApartment/Unit #CityStateZIP CodeHome Phone:Alternate Phone:E-mail Address, if known:Social Security Number:Date of Birth:Employer and Job InformationEmployment Status:Currently EmployedTerminatedNever EmployedTitle:Dates of Employment :Employer Name:Employer Address:Employer Phone Number.
2 Employer Fax Number:Federal EIN:Full/Part Time or Seasonal:Full TimePart TimeSeasonalBegin Date:End Date:Return to Work Date:Employee Work Site or Location:Termination Reason:VoluntaryInvoluntaryWage InformationPay Cycle/Frequency:Rate of Pay: $Gross Pay Per Period: $Net Disposable Pay Per Period: $Current Year-to-Date Earnings: $1 Previous Calendar Year Earnings: $Union Name:Local Number:Mandatory Union Dues: $Mandatory Retirement: $Tax Filing Status:SingleMarriedHead of HouseholdNumber of Dependents:Workers' Compensation:YesNoName of Workers' Compensation Company and Contact Information:Certification InformationCompleted by:Employer Name (Employee's Employer):Name:Title:Signature:Date:Phon e Number:If additional information is needed, please contact the person listed INSURANCE SECTION - Employee Personal InformationFull 4 digits of Social Security Number:Health Insurance AvailabilityDoes the employer offer health insurance?
3 NoYesIf not available currently to the employee, when will it be available?Is health insurance available for dependents or spouse?YesNoIs this paid by:Payroll DeductionPaymentHas the employee enrolled self and/or dependents?SelfDependentsMedical InsuranceInsurance Provider's Name:Insurance Provider's Address:Insurance Provider's Phone:Fax:Policy/Contract Number:Policy Group Name/Number:Cost for Employee Coverage: $Cost for Listed Children: $Cost for Employee/Family: $Cost Frequency:Complete the following information for each dependent:Name (Last, First, Middle)Social Security NumberDate of BirthGroup NumberPolicy NumberStart DateEnd DateDental InsuranceInsurance Provider's Name:Insurance Provider's Address.
4 Insurance Provider's Phone:Fax:Policy/Contract Number:Policy Group Name/Number:Cost for Employee Coverage: $Cost for Listed Children: $Cost for Employee/Family: $Cost Frequency:1 Complete the following information for each dependent:Name (Last, First, Middle)Social Security NumberDate of BirthGroup NumberPolicy NumberStart DateEnd DateVision InsuranceInsurance Provider's Name:Insurance Provider's Address:Insurance Provider's Phone:Fax:Policy/Contract Number:Policy Group Name/Number:Cost for Employee Coverage: $Cost for Listed Children: $Cost for Employee/Family: $Cost Frequency:Complete the following information for each dependent:Name (Last, First, Middle)Social Security NumberDate of BirthGroup NumberPolicy NumberStart DateEnd DatePrescription Drug InsuranceInsurance Provider's Name:Insurance Provider's Address:Insurance Provider's Phone:Fax:Policy/Contract Number:Policy Group Name/Number:Cost for Employee Coverage: $Cost for Listed Children: $Cost for Employee/Family: $Cost Frequency.
5 Complete the following information for each dependent:Name (Last, First, Middle)Social Security NumberDate of BirthGroup NumberPolicy NumberStart DateEnd Date2 Mental Health InsuranceInsurance Provider's Name:Insurance Provider's Address:Insurance Provider's Phone:Fax:Policy/Contract Number:Policy Group Name/Number:Cost for Employee Coverage: $Cost for Listed Children: $Cost for Employee/Family: $Cost Frequency:Complete the following information for each dependent:Name (Last, First, Middle)Social Security NumberDate of BirthGroup NumberPolicy NumberStart DateEnd DateOther Health Insurance(specify type here):Insurance Provider's Name:Insurance Provider's Address:Insurance Provider's Phone:Fax:Policy/Contract Number:Policy Group Name/Number:Cost for Employee Coverage: $Cost for Listed Children: $Cost for Employee/Family: $Cost Frequency:Complete the following information for each dependent.
6 Name (Last, First, Middle)Social Security NumberDate of BirthGroup NumberPolicy NumberStart DateEnd DateCertification InformationCompleted by:Name and Title:Company Name:Signature:Date:Phone Number:3
