Full Text
CENTRE COUNTY DRS CHANGE OF EMPLOYER FORM Client for whom employer change applies(please check one): Your Name and Social Security Number (please print) Your Name and Social Security Number (please print) OLD EMPLOYER: Date Employment Ended Name of Employer Street Address City, State, ZIP Are you collecting unemployment compensation? If so, please indicate date compensation NEW EMPLOYER: Effective Date of New Employment Do you have medical insurance available at new employment? If so, please indicate name of provider and parties covered. Rate of Pay Name of New Employer Name of Provider Street Address Date Coverage Began City, State ZIP Persons Covered by Medical Insurance Signature Date