Employment and salary changes

Please select a plan contract and division number

Please confirm the applicable types of changes

Please select one or more of the following options to make a global change. Related columns in step 3 will show or hide based on these selections.

Salary changes
Terminations
Job classification and/or Billing account changes
Reinstatements

Complete the employment and salary change form

Plan contract Account/division Member certificate Plan member name

Last name / First name / Initial

Effective date of change

dd/mmm/yyyy

Termination/rehire code and return/rehire date

dd/mmm/yyyy

New salary and frequency

$ amount / frequency

Weekly hours Occupation change Class change

old / new

Account/division change Billing division change

old / new

Evd of ins Required Y/N Delete row
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Termination reason codes

  • T- Termination
  • R- Retired or Pensioned
  • LA- Layoff/Complete termination of benefits
  • LB- Temporary layoff of less than or equal to 120 days with no termination of benefits. Ensure "Return date" is specified.
  • LD- Indefinite layoff greater than 120 days with termination of Disability benefits but with continuation of other benefits up to 120 days
  • LE- Leave of Absence with continuation of all benefits over 120 days
  • RE- Reinstatement (must be within the reinstatement period outlined in your contract, and the benefits must be the same as at layoff/termination)

Salary frequencies

  • A- Annual
  • M- Monthly
  • S- Semi-monthly
  • B- Biweekly
  • W- Weekly
  • H- Hourly