Contact Information Separation Form - 2020 Page 1 of 1
901 North Washington Street, Suite 706
Alexandria, VA 22314–1535, United States
Web: aiarc.org, Phone: +1.703.548.4540
Contact Information Separation Form
Please send a signed copy of this completed form to your Center’s AIARC coordinator by email.
This form provides information to contact you once you have separated from your Center.
Participant Name: (Surname, First, Middle)
Separation date from employing Center: (dd/mm/yyyy)
Title of most recent position held:
Name of most recent supervisor:
Permanent Residential Address
Mailing Address (If different from above permanent residential address)
Complete this section only if you will be continuing coverage in the IARC medical insurance plan and/or remaining
in the retirement plan.
Please check the following boxes once you have completed the appropriate form.
IARC Medical Benefit
I have completed the Tax Residency Self-Certification Form.
I have completed the IARC Insurance Plan Change Form
I have updated my beneficiary information in the offshore retirement plan at iarcplan.org
or in the U.S. 403(b) retirement plan at vanguard.com.
Emergency Contact Information
I have updated my emergency contact information below:
(If you want to have more than one emergency contact, please complete a new form for each additional contact.)
Name: (Surname, First, Middle)
Participant Signature Date (dd/mm/yyyy)