Rev 12/11
Louisiana State University
Office of Accounting Services
Payroll
204 Thomas Boyd Hall
EMPLOYEE REQUEST FOR MEDICAL INSURANCE ENROLLMENT AS545
CONFIRMATION FOR VESTING PURPOSES
Request Date ________________________
Employee _______________________________________________ SSN ________________________
List other names primary insurance ______________________________________________________
may have been carried under.
______________________________________________________
Ex: maiden or spouse’s name
______________________________________________________
______________________________________________________
Approximate Dates of Coverage ________________________ _______________________
________________________ _______________________
Complete “Dependent” section only if confirmation is desired on the dependent(s).
Dependent’s Name
Dependent’s SSN
Approximate Dates of Coverage
Reason for Request: 2 Years until Retirement Agency Transfer Other *
Distribution of Information:
Send to Department _________________________________________; Attn _________________________
Mail to ________________________________________________
________________________________________________
This will be picked up. Call ________________________ when available.
__________________________________________ _______________________
Employee’s Signature Date
Note: The Payroll Office will provide the requested information as quickly as possible but a definite turnaround time cannot be
predicted due to the complex nature of the research required. Requests will be completed in order of receipt, unless the
information is needed to complete an immediate retirement.
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FOR ACCOUNTING SERVICES USE ONLY
Mailed by ______________________________ on _____________________ Sent to department
Picked up by _______________________________ on _______________________
* A $25 administrative fee must be
paid in advance if confirmation is
requested for any reason other than
Retirement or Agency Transfer.
Research will not commence until
payment has
been received.
