Print Form
Health/Dental Change Data
A. Employee Information
Name (Last, First, MI): ______________________________________________________________________
Health:
Yes
No
Dental:
Yes
No
Vision:
University ID: _____________
Yes
No
B. Name Change
New Name: ____________________________________________________________________________________________________________
Former Name: __________________________________________________________________________________________________________
C. Address Change
New Address: ______________________________________
____________________
Street
New Phone Number: __________________________________________
Old Address:
_____________________________________
City
____________________
Street
Old Phone Number: __________________________________________
City
____________
_____________
State
Zip
____________
____________
State
Zip
D. Add Dependent(s)
1. Name (Last, First, MI): _________________________________________________________________________________________________
Social Security No.: ______________________________________________
Gender (Check One):
M
F
Date of Birth:______________________________
Relationship to Employee: _____________________________________________________________________________________________
Primary Care Physician (HMO Only): ____________________________________________________________________________________
“Event”: ____________________________________________________________________________________________________________
Date of “Event”: _________________________
2. Name (Last, First, MI): _________________________________________________________________________________________________
Social Security No.: ______________________________________________
Gender (Check One):
M
F
Date of Birth:______________________________
Relationship to Employee: _____________________________________________________________________________________________
Primary Care Physician (HMO Only): ____________________________________________________________________________________
“Event”: ____________________________________________________________________________________________________________
Date of “Event”: _________________________
E. Drop Dependent(s)
1. Name (Last, First, MI): _________________________________________________________________________________________________
Relationship to Employee: _____________________________________________________________________________________________
“Event”: ____________________________________________________________________________________________________________
Date of “Event”: __________________________
2. Name (Last, First, MI): _________________________________________________________________________________________________
Relationship to Employee: _____________________________________________________________________________________________
“Event”: ____________________________________________________________________________________________________________
Date of “Event”: __________________________
Employee Signature: ______________________________________________________________
Date: ________________________________
For Benefits Staff Only
Health: ________________________
Dental: _____________________
Vision: ________________________
UNI: _______________________
Effective Date: ___________________
The University of Northern Iowa is required by federal law to report income along with Social Security Numbers (SSNs) for all employees to whom compensation is paid.
Employee SSNs are maintained and used by the University for payroll, reporting, and benefits purposes and are reported to federal and state agencies in formats required by
law or for benefits purposes. The University will not disclose an employee’s SSN without the consent of the employee to anyone outside the University except as mandated by
law or required for benefits purposes. Responses to items marked “optional” are optional; responses to all other items are required.
Revised 11/2012
BENEFITS
027 Gilchrist  Cedar Falls, IA 50614-0034  Phone: 319-273-2422  Fax: 319-273-2927  http://www.uni.edu/hrs