Verification of Service with Qualified Employer – LTD – Human Resources

Former employee's name

First Last

Hire date of former employee

Termination date of former employee

Full-time equivalency (FTE) of the former employee.

Organizational name of former employer

Organization's Address

Street Address City State ZIP Code

Indicate the primary type of organization

Eligible organizations must be a college, university, or research institute.

Does your organization hold registered not-for-profit status?

Was the former employee eligible to participate in the organization's Long Term Disability plan, if any?

Why was the former employee not able to participate in the Long Term Disability plan?

Name of person completing this form.

First Last

Title of person completing this form.

Email of person completing this form.

Phone number of person completing this form.

Signature of person completing this form.