Fillable Request for Employment Verification (Lake Land College)

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Request for Employment Verification (Lake Land College)

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The Request for Employment Verification (Lake Land College) form is 3 pages long and contains:

  • 1 signature
  • 23 check-boxes
  • 162 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Lake Land College

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State of Illinois
Department of Human Services
Request for Employment Verification
5/7 (Permanent)
IL444-0266 (R-10-17) Request for Employment Verification
Printed by Authority of the State of Illinois -0- Copies
Page 1 of 3
ffad08d6-4936-4e48-8930-bbb9a68d81fb
Date:
Re:
Employee:
Alias:
SSN:
Address:
Case Name:
Case Number:
Employment began: ended: . Number of Hours per week:
Employee's address: (if different from above):
Has he/she received any financial benefits through your firm other than earnings? Yes No
NoYesHas he/she received any disability benefits through your firm?
NoYesAre earned income credit payments being paid with wages?
If Yes, how much?
No - Complete #2B on the reverse.
Yes -- Complete the HEALTH INSURANCE REPORT on the reverse.Is/was employee covered by your health plan?
If yes, please identify and give the date of last payment:
Reason for termination:
Do you plan to rehire? If so, when?
Please provide pay information on an individual pay period basis for the period of
through
If Yes, please identify and give the date of last payment:
Family Community Resource Center
To ensure that public assistance funds are properly disbursed, information concerning the above named person is needed.
We are informed that this person is/was in your employ. Please complete this form and return it in the enclosed envelope.
Payment frequency:
weekly biweekly twice monthly . Rate of pay $
Employee's Social Security Number (if different from above)
Employer's completion of this form or
compliance with instructions is
voluntary. However, failure to do so
may affect this Department's action.
SEE REVERSE
Pay Period
Ending
Date Paid Gross Pay Tips
Pay Period
Ending
Date Paid Gross Pay Tips
State of Illinois
Department of Human Services
Request for Employment Verification
5/7 (Permanent)
IL444-0266 (R-10-17) Request for Employment Verification
Printed by Authority of the State of Illinois -0- Copies
Page 2 of 3
ffad08d6-4936-4e48-8930-bbb9a68d81fb
1. Case Name:
Group:
2a.Policy Holder/Employee Last, First and MI:
DATE OF BIRTH
Check if employee/dependent is not covered by a group health plan through your organization.
2b.
Employee/dependent may enroll on
.
Check if health insurance is available at no cost to employee or dependent.
3. Complete for insurance through Employer/Union
Employer/Union: Union Local #:
Street:
City: State: Zip:
4. Where Are Claims Mailed?
Zip:State:City:
Street:
Medical Claims sent to Name
Zip:State:City:
Street:
Prescription Drug Claims to - Name:
5. Check all the Following Benefits that are Provided
Major Medical Dental Vision LTC RX Drug
RX Card #:
Health Insurance Report
Insurance Company:
Certificate/Policy Number:
LAST FIRST MI
SOCIAL SECURITY NUMBER INSURANCE BEGIN DATE INSURANCE END DATE
Check if health insurance is available but has not been chosen for: employee
dependents
Monthly Premium $
Monthly Premium $
6. Complete for Employee and Dependent Coverage
*ENTER RELATIONSHIP TO
POLICYHOLDER CODE
(POLICYHOLDER-0, SON-1,
DAUGHTER-2, SPOUSE-3, STEPCHILD-4,
GRANDCHILD-5, OTHER-6)
2c.
Case Number:
Last Name First Name
Recipient Number
(DHS Use Only)
Date of Birth
Insurance
Began Date
Insurance
End Date
*
Date:
State of Illinois
Department of Human Services
Request for Employment Verification
5/7 (Permanent)
IL444-0266 (R-10-17) Request for Employment Verification
Printed by Authority of the State of Illinois -0- Copies
Page 3 of 3
ffad08d6-4936-4e48-8930-bbb9a68d81fb
8. Completed By:
Signature
Telephone Number: Date:
9. DHS USE ONLY: SEND PHOTOCOPY OF COMPLETED FORM TO THIRD PARTY LIABILITY, BUREAU OF
COLLECTIONS.
ORIGINALCheck One UPDATE CHECK
IF TPL IDENTIFIED THROUGH DATA EXCHANGE
- CROSSMATCH OR PAL CODE:
Worker:
Date:
CENTRAL OFFICE USE ONLY OLD TPL RDB
7. Complete if person(s) in #6 were insured by you under a previous plan.
Name of Previous Carrier: Group Number:
End Date:Begin Date:
Zip:State:City:
Street:
REMARKS: (IDENTIFY LIMITED POLICY, REASON FOR UPDATE, ETC.)
FRC: Referring Office (if not Local Office):
Date:
Case Number:
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Request for Employment Verification (Lake Land College)

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Completed 12 September 2021

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