NEW HIRE/CHANGE FORM
Original Document
You are encouraged to review the original document prior to completing this form. Your answers will be embedded on the PDF form and submitted to the proper department.
Type
New Hire
Name Change
Address Change
Beneficiary Change
Other
Name
Social Security Number
Gender
Please Select
Female
Male
Address
Home Address
Street Address Line 2
City, State
State / Province
Zip
Date of Birth
/
Month
/
Day
Year
Date
Job Title
Department
Work #
Cell #
Email
example@example.com
Date of Hire
/
Month
/
Day
Year
Date
Effective Date of Coverage
/
Month
/
Day
Year
Date
Annual Salary
Certified/Classified
Please Select
Certified
Classified
Hours/week
Employee ID#
Type of QLE
Date of QLE.
/
Month
/
Day
Year
Date
Effective Date of Coverage
/
Month
/
Day
Year
Date
Dependent Information
First Name
Last Name
DOB
Gender
Relationship to Employee
1st
Female
Male
2nd
Female
Male
3rd
Female
Male
4th
Female
Male
Beneficiary Information
First Name
Last Name
DOB
Relationship to Employee
Primary or Secondary
Percentage
1st
Primary
Secondary
2nd
Primary
Secondary
3rd
Primary
Secondary
DENTAL COVERAGE (DELTA DENTAL)
Employee - $33.96/mo
Employee + Family - $96.20/mo
Decline
VISION COVERAGE (VSP)
Employee - $8.41/semi-mo
Employee + 1 - $13.46/semi-mo
Employee + Children - $13.74/semi-mo
Employee + Family - $22.15/semi-mo
Decline
Long Term Disability is fully paid for by Gentry School District
Signature
Date
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: