Please Allow up to 24 Hrs. for Change to Take Effect

Employee Action Form

I’m here to process a:
Promotion / Go to Section A / Demotion / Go to Section A
Transfer / Go to Section A / Re-Org / Go to Section B
Termination / Go to Section C / Other

-Please allow up to 24 hrs. for change to take effect-

Should you have any questions, please contact your HR office

Please Email completed form to your HR office

Janel Garcia / Theresa Roelofs / Brett Richardson
Sarah Grill / Emily Hemminger / Katie Pimentel
Carly Workman
Affected Employee Name:
(First, Middle, Last) (if re-org, please go to Section B)
Current Supervisor:
Effective Date:
Form Submitted By:
Title:

Section A Employee Change

Current / New
Title:
Dept/Branch:
Office Location:
Work Phone #:
Supervisor:
Pay Rate (Hrly/Salary):
%Inc/Dec: / Right click on the next cell to “update field” for calculation
If this change affects other EEs please complete Section B. (e.g. different branch # or supervisor)
Additional Comments:

Section B Additional Changes

Complete this section for the other employees affected or for a Re-org

EE Name / Information / Title / Reports-To / Dept/Branch
Current
New
Current
New
Current
New
Current
New
Current
New
Current
New
Current
New
Current
New
Current
New
Additional Comments:

Section C Employee Termination

*Does the employee have a Home Phone/Cell Phone/Fax provided by the company? Select OneYesNo
*Does the employee have a Company Laptop or other equipment? Select OneYesNo
*Have all keys/key fobs/security badges been collected? Select OneYesNo
If yes, please make arrangements to cancel these services and/or retrieve all York Equipment
Involuntary Termination: Select OneDeathMisconduct/Policy ViolationReduction in Force/LayoffSubstandard PerformanceVisa Expiration / Voluntary Termination: Select OneCareer Instability due to mergerCareer OpportunityClient LeavingHealthEarly RetirementEnd of Temporary AssignmentJob AbandonmentJob Dissatisfaction - Comp, Benefits, 401k, etc.Job Dissatisfaction - Lack of Career AdvancementJob Dissatisfaction - Lack of TrainingJob Dissatisfaction - WorkloadNot Returning From LeavePersonal/Family ReasonsResigned due to performance deficienciesRetirement / Early RetirementUndisclosed
Last Day of Employment: / Amount of Vacation/PTL due:
Assign open diaries in Claims Connect to:
Should Voice/Fax and Email Accounts be forwarded? Select OneYesNo, Please forward to: For How Many Day? Select One30 Days60 Days90 Days
Forwarding Email: / Forwarding Phone #:
*Submit Separate Helpdesk Service Request to move Open Claims Connect Claims
Select all systems this employee had accounts with (Check all that apply):
AIM / Claims Connect / Gates 2000 WC Claims / Staples CMS
ALFL Sorsa Payments / Coverall / Gates 2000 WC Payments / VCS.net
ALGL Crown Claims / CSO or LMS / Goldmine / VOS
ALGL Crown Payment / Cyprus / ICE / VPN
ALGL Sorsa Claims / Dolphin (BWC) / IFX (Progressive Medical) / Other
Atlantis / G2 Weblink / Sears CMS
Additional Comments:

Employee Action Form

Revised: 4/2016