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Employee Change Form Employee Name (Last, First) Agency Name, Social Security Number (SSN) or Date of Birth (DOB) Change Address Change III-A will allow you to terminate the employee/retiree or qualified dependent(s) retroactively up to two months from the time the request for termination is received by the III-A. However, if any claims have been incurred during the time of retroactive termination, the employee, retiree or dependent will be responsible for any amounts paid. Benefit Coverage Changes Prepared by: Date: If you have questions, call III-A Benefits Manager, at [PHONE REDACTED] or email [EMAIL REDACTED]. To submit form, fax to [PHONE REDACTED] or request a secure email form the Benefits Manager. Employee ☐ Spouse ☐ Child ☐ Current Name, SSN or DOB: New Name, SSN or DOB Current Address: (Street, City, State, Zip) New Address: (Street, City, State, Zip) Add ☐ Delete ☐ Employee ☐ Spouse ☐ Child ☐ Female ☐ Male ☐ Name: (Last, First) SSN: Date of Birth: Medical ☐ Dental ☐ Vision ☐ Reason for Change: (marriage, birth, open enrollment etc.) Date of Qualifying Event: Add ☐ Delete ☐ Employee ☐ Spouse ☐ Child ☐ Female ☐ Male ☐ Name: (Last, First) SSN: Date of Birth: Medical ☐ Dental ☐ Vision ☐ Reason for Change: (marriage, birth, open enrollment etc.) Date of Qualifying Event: ---PAGE BREAK--- Add ☐ Delete ☐ Employee ☐ Spouse ☐ Child ☐ Female ☐ Male ☐ Name: (Last, First) SSN: Date of Birth: Medical ☐ Dental ☐ Vision ☐ Reason for Change: (marriage, birth, open enrollment etc.) Date of Qualifying Event: Add ☐ Delete ☐ Employee ☐ Spouse ☐ Child ☐ Female ☐ Male ☐ Name: (Last, First) SSN: Date of Birth: Medical ☐ Dental ☐ Vision ☐ Reason for Change: (marriage, birth, open enrollment etc.) Date of Qualifying Event: Add ☐ Delete ☐ Employee ☐ Spouse ☐ Child ☐ Female ☐ Male ☐ Name: (Last, First) SSN: Date of Birth: Medical ☐ Dental ☐ Vision ☐ Reason for Change: (marriage, birth, open enrollment etc.) Date of Qualifying Event: Add ☐ Delete ☐ Employee ☐ Spouse ☐ Child ☐ Female ☐ Male ☐ Name: (Last, First) SSN: Date of Birth: Medical ☐ Dental ☐ Vision ☐ Reason for Change: (marriage, birth, open enrollment etc.) Date of Qualifying Event: