Fillable Form 2.: CURRENT FORMER IDAHO STATE SERVICE AND (Boise State University)

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Form 2.: CURRENT FORMER IDAHO STATE SERVICE AND (Boise State University)

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CURRENT
AND
FORMER
IDAHO STATE
SERVICE
1.
Legal
Name
SS#
2.
Idaho State
Employment
Status
:
Transfer Employee Former Employee PERSI Retiree
Non-Transfer Employee
(“
Non-Transfer Employee” applies if you are currently
on benefits with another Idaho state agency and you are being hired in an additional
appointment at BSU.)
3.
State
Agency
Name:
4.
Original Hire
Date with
the State:
Month Day Year
5.
Separation
Date from Previous State Agency
(if
applicable):
Month ___Day Year
6.
Retirement
Plan:
AIG VALIC PERSI TIAA-CREF
7. If you are a
transfer
employee, are you currently enrolled in any of the following
plans?
Flexible Spending P CNCPERS ERSI hoice 403(b) 457(b)
Blue Cross Enrollment: Traditional
nt: M h
PPO Supplemental Life Insurance
8. If you are a
PERSI
Retiree
, enter your date of retireme ont Day Yr
9. If you are a
Non-Transfer
Employee
, we are required to deduct retirement
contributions from your BSU paycheck. Please be sure to indicate your retirement plan
on line 6.
I
f
you
have questions
about
this form,
please
ask to speak with
a
benefit staff member.
10/06
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Form 2.: CURRENT FORMER IDAHO STATE SERVICE AND (Boise State University)

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Completed 17 August 2020

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