Fillable Benefits User Security Authorization *All Requesting Agency Information (State of Tennessee)

Fill Online, Printable, Fillable, Blank Benefits User Security Authorization *All Requesting Agency Information (State of Tennessee) Form

Use Fill to complete blank online STATE OF TENNESSEE (TN) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Benefits User Security Authorization *All Requesting Agency Information (State of Tennessee)

On average this form takes 13 minutes to complete

The Benefits User Security Authorization *All Requesting Agency Information (State of Tennessee) form is 2 pages long and contains:

  • 3 signatures
  • 13 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State of Tennessee

BROWSE STATE OF TENNESSEE (TN) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Benefits User Security Authorization
User’s Name
User’s Empl ID
User’s Edison ID
1 Submit this form to benefits.training@tn.gov
FA – 1016 (Revised 10/12/2020) RDA SW25
Indicate User Type: State Employee Contractor External (Higher Ed, Loc Ed, Loc Gov)
Effective Date:
Role Addition Only Role Removal Only
Data Level Security Modification - Add to current dept id access
Data Level Security Modification - Remove a current dept id
Data Level Security Modification - Remove current dept id access and add the new access
identified on page 2
*All Requesting Agency Information and User Information is Required Unless Otherwise Noted
Requesting Agency Information
Agency Name
Agency Bus Unit
Requester Name
Requester Edison Access ID (BA Only)
Requester Phone Number
Requester Email
User Information
First Name
Last Name
Birth Month
Birth Day
Year
(if contractor)
Organization/Vendor (if not state employee)
Last 4 digits of SSN
(if not state employee)
User’s Department ID:
Employee ID, if state employee:
Email Address:
Phone Number:
Security Authorization Signatures
Agency
Authorization: ______________________ ____________________________ _________________
Signature Print Name/Title Date
Benefits Administration
Authorization: ______________________ ____________________________ _________________
Signature Print Name/Title Date
Additional
Authorization: ______________________ ____________________________ _________________
Signature Print Name/Title Date
Description of change needed:
NOTE: RECEIPT DATE MUST BE WITHIN 30 DAYS OF SIGNATURE DATE
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Benefits User Security Authorization
User’s Name
User’s Empl ID
User’s Edison ID
2 Submit this form to benefits.training@tn.gov
External Agency Benefits
Data Access Levels – Please indicate the required access levels below.
Department Level
(Access to a single department within a BU)
Multiple Departments (Access to multiple
departments within a BU)
If security access to Multiple Departments is required, list the departments or agencies to which the user
will need access. If needed, departments can be listed on an Excel spreadsheet.
External Agency Coordinators
BA-1013 BA External Agency
Benefits Coordinator
BA-1017 Benefits Inquiry Only
EL-3011 Ext Agency Learner
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Benefits User Security Authorization *All Requesting Agency Information (State of Tennessee)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document