ERP NOTICE OF CHANGE/NEW PARTICIPANT ENROLLMENT
(To Be Completed By Employer)
Location No.
Employer Name:
Return this form to:
Christian Brothers Retirement Services
1205 Windham Parkway
Romeoville, IL 60446-1679
Fax: 630-378-2507
E-mail: rpscustomerservice@cbservices.org
City/State:
Zip Code:
Section 1 - Employee Data
Employee Last Name:
First Name:
Middle:
Street Address: _____ (check if new)
City/State:
Zip Code:
Soc. Sec. No.:
Date of Birth:
Sex:
M F
Marital Status: (Circle One)
Single Married Widowed Divorced
Spouse’s Name : ________________________________
Spouse’s DOB: ________________________________
Spouse’s SS#: ________________________________
Section 2 - New Employee Eligibility
Date of Hire:
Part-Time ____ (Check one) Full-Time ____
(Less than 20 hrs) (20 hrs or more)
Probationary Period: ___ Yes ___ No If Yes # of months: 1 3 6 9 1 yr (circle one)
Date Eligible to Participate (20 hours or more): _____/_____/_____
(Mo) (day) (year)
Section 3 - Change of Status After Enrollment
Enter Code No.
(select from descriptions below):
Effective Date:
(last date worked) ______/_______/_______
(mo) (day) (year)
Last Pension Report to appear on: (MM/YY)
Code No:
1
2
3
4
5
6
7
8
9
10
Code Description:
Termination From Plan
_____Address _____ Name Change (check applicable item)
Death
Retirement
Leave of Absence (Without Pay)
Return from Leave of Absence
Disability
Transfer
Rehire
Other (please specify): ________________________________________________________________
Emplo