Change of Address or Name Form Packet

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Austen Dennis
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Change of or Form Packet Directions: If you are a certified employee, complete pages 2, 3, and 4. If you are a classified employee, complete pages 2, 3, and 5.

1 Change of or Form Packet Directions: If you are a certified employee, complete pages 2, 3, and 4. If you are a classified employee, complete pages 2, 3, and 5. PAGE 2: Change of or Form - Complete the first page of this document with standard name or address change information. Sign and date the form; return to district. PAGE 3: 2015 KEHP Update Form This is the form that will be used to update information on health insurance, FSAs and HRAs. Complete the information, sign and date the form, and return to the district. PAGE 4: Kentucky Teachers Retirement System: Change of or Form Complete this form if you are a certified employee. It is YOUR responsibility to return the form to KTRS. Fax: Mail: Kentucky Teachers Retirement System, 479 Versailles Road, Frankfort KY PAGE 5: Kentucky Retirement Systems: Change of Notification Complete this form if you are a classified employee. It is YOUR responsibility to return the forms to KRS. Fax: Mail: Kentucky Retirement Systems, Perimeter Park West, 1260 Louisville Rd, Frankfort KY For other Benefits packages: 5 Star Life Insurance - Contact the 5 Star Life Insurance Company ( ) and ask them to send you a Policy Change Form. American Fidelity - Visit their website at for the necessary change forms. AFLAC - Visit their website at for the necessary change forms. Nationwide State Life Insurance - For beneficiary changes, contact the HR department. Kentucky Deferred Comp - Contact them directly at KEA/KESPA - Contact them directly (800)

2 Change of or Form Packet This form is used to change your demographic data in Payroll and Benefits. City/State/Zip CHANGE OF ADDRESS OR NAME FROM: City/State/Zip CHANGE ADDRESS OR NAME TO: Please check accordingly Permanent OR Temporary Check all that apply: I will contact the Benefits Office to change beneficiary information for life insurance and/or retirement. I will contact the Benefits Office to change optional insurance or other payroll deductions. Do you have children in Hopkins County Schools? Yes No Signature Signed Contact the Benefits Office: Phone Extension #2409 carrie.slation@hopkins.kyschools.us

Kentucky Employees Health Plan Department of Employee Insurance http://kehp.ky.gov 1.888.581.8834 2017 KEHP UPDATE FORM To be completed by Insurance Coordinator/HR Generalist only.

3 Kentucky Employees Health Plan Department of Employee Insurance KEHP UPDATE FORM To be completed by Insurance Coordinator/HR Generalist only. DO NOT use this form to add or drop dependents. This form is to be used to update information on health insurance, FSA and HRAs. General Information (required) : Personnel Number: SSN: Organizational Unit: Company Number: Company : Update Reason Termination: Employment Ends Health Insurance Terminates Reason: Resigned Retired LWOP Death Military Leave Other Reinstate Coverage: Returned to Work Health Insurance Effective Reason: Rehired FMLA LWOP Military Leave Other Transfer or Summer Transfer: Is member Cross Reference? Yes No To be completed by the NEW company No changes to current coverage allowed Prior Company Number Last Day Worked at Prior Company Coverage End at Prior Company New Company Number Hired at New Company Coverage Begin at New Company LivingWell CDHP LivingWell PPO Standard PPO Standard CDHP Current Health Benefit Option Current Coverage Level Current FSA Option Waiver Dental/Vision ONLY HRA Waiver without HRA - No $ Waiver (General Purpose) HRA Single(self only) Parent Plus (self and child(ren)) Couple (self and spouse) Family (self, spouse and child(ren)) Other Changes or Corrections For: Member Spouse Child(ren) New (Where mail received) New: Previous: Street : Healthcare FSA City: State: ZIP Code: County: SSN Correct: Incorrect: of Birth Correct: Incorrect: Other Dependent Care FSA Total Calendar Year Contribution: $ I acknowledge and understand that DEI will comply with HIPAA rules and that disclosure of information will be done under the rules of such Federal law. I further authorize DEI to use such information and to disclose such information to third party administrators, vendors, consultants, governmental authorities with jurisdiction and other necessary parties when necessary for my care or treatment, payment for services, the operation of my health plan or to conduct related activities. Employee Signature IC/HRG Signature IC/HRG Printed IC/HRG Phone Number 2017 Update Form Rev. 09/2016

4 KENTUCKY TEACHERS RETIREMENT SYSTEM Change of or Form As an active or retired teacher or survivor of a member of the Kentucky Teachers' Retirement System, I request that the information be changed as follows: (A valid signature is required in order to process this change.) CHANGE OF ADDRESS or NAME FROM: City/State/ZIP New New New City/State/ZIP New Phone Number CHANGE ADDRESS or NAME TO: Please Check Accordingly Permanent OR Temporary The following information must be completed upon submission of this form. County of Residence KTRS Member Identification Number Please circle one: Active or Retired Member/Survivor s Signature Send Beneficiary Change Form: yes no, 20 Return to: FAX to: Kentucky Teachers' Retirement System Active Members FAX to: 502/ Versailles Road Retired Members FAX to: 502/ Frankfort, KY Forms/EFT/2010-doc

5 Kentucky Retirement Systems Perimeter Park West 1260 Louisville Rd. Frankfort KY Phone: (502) Fax: (502) kyret.ky.gov Form 2040 Revised 10/2005 Change of Notification In order for Kentucky Retirement Systems to insure proper mail delivery, please complete the following and return this form to our office as soon as possible. Member Information Please provide your Member ID or Social Security number in the Member ID box below. Member : Member ID: : City: State: Zip Code: Daytime Phone Number: Please check the appropriate box below: Not receiving a monthly benefit (Active Member) Presently drawing a monthly benefit (Retired Member) Important Notice If a fiduciary is completing this change of address form on behalf of the member, a copy of the power of attorney, or order appointing guardianship, or other document, must be submitted with this form. Persons acting as a fiduciary should sign this and other retirement systems documents so that the capacity in which the document is being executed is exactly clear. If you are acting as a Power of Attorney, you must sign in the name of the principal followed by your signature as the attorney-in-fact with the designation POA or AIF. For example: John Doe by Jane Doe, POA. If you are acting as a Guardian, you must sign in the name of the ward followed by your signature as the guardian with the designation Guardian. For example: John Doe by Jane Doe, Guardian. If you have further questions, you may contact a counselor in writing or by telephone. Kentucky Retirement Systems (KRS) addresses are now being updated monthly with the address on file for you with the U.S. Post Office. This is done through the National Change of (NCOA) system. Therefore, it is very important that you make sure your current address is on file with your local Post Office. Otherwise, when NCOA updates the KRS address records next month, your address may be replaced with an incorrect address; and mail from KRS may not be forwarded by the Post Office. Signature: :

New Employee Benefits Package CERTIFIED EMPLOYEES

Hopkins County Schools New Employee Benefits Package CERTIFIED EMPLOYEES In this packet, you will find the following insurance forms. Please print this package and complete the forms listed below. Bring