Life Status and/or Information Change Form

Life Status and/or Information Change Form
Employee Name Currently on Record with CCS:*
Employee's NEW Legal Name (if applicable):*
Last Four Digits of Social Security Number:*
last four digits only
Employee #/Timekeeper ID:*
Email Address:*
Current Mailing Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone*
Cell Phone*
Site/Location*
Job Title*
Reason for Name Change*

Marriage: Attach a copy of two of the following: Marriage Certficate, Social Security Card, and/or Drivers License (both should reflect new name)Divorce: Attach a copy of 1st page & Signature page of Divorce Papers OR Social Security Card and Drivers License (both should reflect legal name)
Please attach required documents for this Name Change*

Browse Files

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If your life/family status change has occurred during the past 30 days, do you need to change any of your insurance elections? (i.e. add, change, or cancel a policy, or add/remove a dependent(s)*

Yes - please email Danielle Hood as soon as possible regarding the change you need to make to your policiesNo, I do not need to make any changes to my insurance policies
Do you need to Change your Beneficiaries on your Benefits?*

Yes, please email me the beneficiary change directionsNo, my beneficiaries on file are accurate
Signature*

Clear
Date*

MonthDay Year
Should be Empty: