Fillable Standard Response to Verification of Employment (U.S. Department of Health & Human Services)

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Standard Response to Verification of Employment (U.S. Department of Health & Human Services)

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  • 21 check-boxes
  • 335 other fields

Country of origin: US
File type: PDF

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Standard Response to Verification of Employment
Employers will provide requested information normally maintained on employees. If additional information not
listed on this form is needed, please contact the employer.
PAYROLL SECTION - Employee Personal Information
Full Name:
Last
First M.I.
Residential
Address, if known:
Street Address Apartment/Unit #
City State ZIP Code
Mailing Address,
if known:
Street Address Apartment/Unit #
City State ZIP Code
Home Phone: Alternate Phone:
E-mail Address, if known:
Social Security Number:
Date of Birth:
Employer and Job Information
Employment Status:
Currently Employed
Terminated
Never Employed
Title:
Dates of
Employment:
Employer Name:
Employer
Address:
Employer
Phone
Number:
Employer
Fax
Number:
Federal EIN:
Full/Part Time or
Seasonal:
Full Time Part Time
Seasonal
Begin Date:
End Date:
Return to Work Date:
Employee Work Site or Location:
Termination Reason:
Voluntary
Involuntary
Wage Information
Pay Cycle/Frequency:
Rate of Pay: $
Gross Pay Per Period: $ Net Disposable Pay Per Period: $
Current Year-to-Date Earnings: $
1
Previous Calendar Year Earnings: $
Union Name: Local Number:
Mandatory Union Dues: $ Mandatory Retirement: $
Tax Filing Status:
Single
Married
Head of Household
Number of Dependents:
Workers' Compensation:
Yes No
Name of Workers' Compensation
Company and Contact Information:
Certification Information
Completed by:
Employer Name (Employee's Employer):
Name:
Title:
Signature:
Date:
Phone Number:
If additional information is needed, please contact the person listed above.
2
HEALTH INSURANCE SECTION - Employee Personal Information
Full Name:
Last
First M.I.
Last 4 digits of Social Security Number:
Health Insurance Availability
Does the employer offer health insurance?
NoYes
If not available currently to the employee, when will it be available?
Is health insurance available for dependents or spouse?
Yes No
Is this paid by:
Payroll Deduction Payment
Has the employee enrolled self and/or dependents?
Self Dependents
Medical Insurance
Insurance Provider's Name:
Insurance Provider's Address:
Insurance Provider's Phone: Fax:
Policy/Contract Number:
Policy Group Name/Number:
Cost for Employee Coverage: $
Cost for Listed Children: $
Cost for Employee/Family: $
Cost Frequency:
Complete the following information for each dependent:
Name
(Last, First, Middle)
Social Security
Number
Date of
Birth
Group
Number
Policy
Number
Start Date End Date
Dental Insurance
Insurance Provider's Name:
Insurance Provider's Address:
Insurance Provider's Phone: Fax:
Policy/Contract Number:
Policy Group Name/Number:
Cost for Employee Coverage: $
Cost for Listed Children: $
Cost for Employee/Family: $
Cost Frequency:
1
Complete the following information for each dependent:
Name
(Last, First, Middle)
Social Security
Number
Date of
Birth
Group
Number
Policy
Number
Start Date End Date
Vision Insurance
Insurance Provider's Name:
Insurance Provider's Address:
Insurance Provider's Phone: Fax:
Policy/Contract Number:
Policy Group Name/Number:
Cost for Employee Coverage: $
Cost for Listed Children: $
Cost for Employee/Family: $
Cost Frequency:
Complete the following information for each dependent:
Name
(Last, First, Middle)
Social Security
Number
Date of
Birth
Group
Number
Policy
Number
Start Date End Date
Prescription Drug Insurance
Insurance Provider's Name:
Insurance Provider's Address:
Insurance Provider's Phone: Fax:
Policy/Contract Number:
Policy Group Name/Number:
Cost for Employee Coverage: $
Cost for Listed Children: $
Cost for Employee/Family: $
Cost Frequency:
Complete the following information for each dependent:
Name
(Last, First, Middle)
Social Security
Number
Date of
Birth
Group
Number
Policy
Number
Start Date End Date
2
Mental Health Insurance
Insurance Provider's Name:
Insurance Provider's Address:
Insurance Provider's Phone: Fax:
Policy/Contract Number:
Policy Group Name/Number:
Cost for Employee Coverage: $
Cost for Listed Children: $
Cost for Employee/Family: $
Cost Frequency:
Complete the following information for each dependent:
Name
(Last, First, Middle)
Social Security
Number
Date of
Birth
Group
Number
Policy
Number
Start Date End Date
Other Health Insurance(specify type here):
Insurance Provider's Name:
Insurance Provider's Address:
Insurance Provider's Phone: Fax:
Policy/Contract Number:
Policy Group Name/Number:
Cost for Employee Coverage: $
Cost for Listed Children: $
Cost for Employee/Family: $
Cost Frequency:
Complete the following information for each dependent:
Name
(Last, First, Middle)
Social Security
Number
Date of
Birth
Group
Number
Policy
Number
Start Date End Date
Certification Information
Completed by:
Name and Title:
Company Name:
Signature:
Date:
Phone Number:
3
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Standard Response to Verification of Employment (U.S. Department of Health & Human Services)

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Completed 14 October 2021

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