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Notice of Change of Address
Please print, complete and submit to:
Full Name:
ID Number:
Department:
Old Address:
New Address:
New Phone:
Office of Human Resources
3800 Hillsborough Street
Raleigh, NC 27607-5298
_(___________)____________________________________________
Effective Date of Change: __________________________________
Signature: _________________________________________________________
Please note: If you are benefit eligible, the Office of Human Resources will change your
address with most of your benefit carriers.
You will need to change your information with the following carriers: TIAA, Life
Lock and HSA Bank.
For HR Office Use:
Datatel Updated: ______________
Medical Insurance Dental Insurance Vision Insurance
Life Insurance Medical Flex Long Term Disability Medical Flex
SimplyWell Dependent Care Flex AllState Accident / Critical Illness
HR: ______________________________________ Date: ____________________
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