Employee Occupation Certification

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Employee Occupation Certification Powered By Docstoc
					                                                                Department of Employee Trust Funds
                                                                              P.O. Box 7931
                                                                            Madison, WI 53707
                                                   ACCUMULATED LEAVE CERTIFICATION
                                                Wis. Stat. § 40.05 (4) (b) and Wis. Stat. § 40.02 (25) (b) and (bc)
Complete this form for each terminating
employee who:                                                  1. Is age 55 or over (age 50 if protective occupation); OR
                                                               2. Is applying for a disability benefit; OR
                                                               3. Died; OR
                                                               4. Qualifies for delayed sick leave usage under 1991 WA 39 (Public Official); OR
                                              5. Qualifies for delayed sick leave usage under 2003 WA 33 (Employee Terminating
                                                 after 20 years but not eligible for immediate annuity)
THIS FORM MUST BE SUBMITTED WITHIN 30 DAYS AFTER TERMINATION. DO NOT SUBMIT BEFORE TERMINATION. TYPE OR PRINT IN INK.

EMPLOYE INFORMATION
Name (Last, First, Middle, Former)                             Social Security Number                 Birthdate (MM/DD/YY)
                                                                        XXX-XX-
Address (Street or P.O. Box No., City, State, Zip Code)                          Employment Category
                                                                                     Non-Teacher                Teacher
Sex                           Termination Date or Date of Death (MM/DD/YY)       Reason for Termination (see above)
      Male          Female                                                        1         Retirement                3      Death     5       WA 33
                                                                                  2         Retirement-Disabled       4      WA 39
                                                                                  Position Title:
Does employe have health insurance                 Is spouse employed by State of Wisconsin?      Is employe dependent on spouse’s STATE contract?
coverage?
      Yes          No                                  Yes      No          Don't Know         N/A        Yes                 No            Don't Know


HEALTH PLAN NFORMATION (Complete Spouse’s health carrier information if employe is dependent on spouse’s state contract)
Health Plan                                        Health Plan Code                      Coverage Type                                Group No.
                                                                                            Single           Family                                 83445
SPOUSE/DEPENDENT INFORMATION
Name (Last, First, Middle, Former)                             Social Security Number                 Birthdate (MM/DD/YY)
                                                                        XXX-XX-
CERTIFICATION OF ACCUMULATED LEAVE
                                                                                                                                           * NOTE: In most cases the
a) Enter unused sick leave hours (enter 0 if none)                                                                                         highest basic pay will be used,
                                                                                                                                           however there are some
b) Add other creditable leave hours (see instructions in Heath Insurance Manual)                                                  0.00     exceptions. Please refer to
c) Total Hours (a + b)                                                                                                            0.00     current bargaining agreements
d) Highest Basic Pay Rate as State Employee                                                                                     $0.000     for represented employees. For
                                                                                                                                           some employees line g) will be
e) Amount Certified (c x d)                                                                                                      $0.00     calculated using the ending
                             FOR EMPLOYER USE ONLY                                                                                         base pay rate, or, at the
            Seniority Date                               Bargaining Unit:                                                                  employee’s request, the
                                                                                                                                           average of the employee’s
       Years of service equal to or less than 24                                               0.00
                                                                                                                                           base pay rates during the three
               Years of service greater than 24                                                0.00                                        highest years. Contact the
f) Enter Supplemental Sick Leave hours (include extra 500                                                                                  Office of State Employment
hours if applicable)                                                                           0.00                               0.00     Relations for clarification.
g) Highest Basic Pay Rate as State Employee *                                                                                   $0.000
h) Amount Certified (f x g)                                                                                                      $0.00
Enter an Y in the box if the extra 500 hours are included:
                TOTAL AMOUNT CERTIFIED (e + h)                                                                                     $0.00
Premiums have been paid for coverage through (MM/YY)
EMPLOYER INFORMATION                                                                                                                       Group No.
                                                                                                                                                                  83445
Date (Mo/Day/Yr)                  Signature of Agent                             Contact Name and Phone                   Employer Name
              01/31/11             Richard C. Laufenberg                                                                  University of Wisconsin
                   FOR EMPLOYE TRUST FUNDS USE ONLY
 Effec. Date (MM/YY)            Coverage Type           Premium Amount                   Submit to ETF at above address.
                                                                                         Keep a copy for your records.
ET-4306 (REV 03/2006)
            Supplemental Sick Leave Credits
 Years of             Hours of                 Hours of
 Adjusted             Matching                Matching
Continous             Credits-                 Credits-
  Service             General                 Protective
   15                     780                   1170
   16                     832                   1248
   17                     884                   1326
   18                     936                   1404
   19                     988                   1482
   20                    1040                   1560
   21                    1092                   1638
   22                    1144                   1716
   23                    1196                   1794
   24                    1248                   1872
   25                    1352                   1976
   26                    1456                   2080
   27                    1560                   2184
   28                    1664                   2288
   29                    1768                   2392
   30                    1872                   2496
   31                    1976                   2600
   32                    2080                   2704
   33                    2184                   2808
   34                    2288                   2912
   35                    2392                   3016
       Health Carrier Name   Code
ATRIUM                        39
COMPCAREBLUE AURORA FAMILY    16
COMPCAREBLUE NORTHWEST        13
COMPCAREBLUE SOUTHEAST        11
DEAN HEALTH PLAN              15
GHC - EAU CLAIRE              30
GHC - SOUTH CENTRAL           35
GUNDERSON LUTHERAN            37
HEALTH TRADITION              55
HUMANA EASTERN                21
HUMANA WESTERN                22
MEDICAL ASSOCIATES HMO        63
MERCYCARE                     64
NETWORK                       70
PHYSICIANS PLUS               74
PREVEA HEALTH PLAN            47
STANDARD PLAN                 01
STATE MAINTENANCE PLAN        05
UNITED HEALTHCARE NE          94
UNITY - COMMUNITY             40
UNITY - UW HEALTH             92
WPS PATIENT CHOICE 1          81
WPS PATIENT CHOICE 2          82
WPS PREVEA HEALTH PLAN        47

				
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Description: Employee Occupation Certification document sample