Diocese of Winona Notice of Dow to Complete : Pension No Pension

ð Benefit Eligible Yes No

Diocese of Winona Notice of Dow to complete: Pension No Pension

New employee hire Employee Termination Name change

or Increase in Hours or Reduction in Hours (Complete through city/state/zip)

Date: / Parish/School Name:
Employee Information

First Name:

/ /

M.I.:

/ /

Last Name:

/
Address:
City, State, Zip: / Home Phone #
Date of Birth: / Social Security #:
Start date or date hours increased: / Transfer from:
Job Title: / If teaching, license #:
Will the new employee work with children or young adults: Yes No
Has the new employee worked at a Catholic school/church/institution within the Diocese of Winona in the last 5 years: Yes No
Qualifying Event Information (check one)
New hire or increase in hours: / Termination or decrease in hours
New Hire or Increase in hours / ð Effective date
(from less than 20 to 20 or more per week / Termination of employment – involuntary and/or reduction of
hours to less than 1000 hours per year (attach termination letter)
ð Exempt employee Yes No / Voluntary separation of employment, resignation or
If yes above, attach job description / quit (attach resignation letter)
ð Number of hours per week employee will work: / Retirement
ðNumber of months per fiscal year / Reduction in hours (more than 1040 hours per year)
ð Annual salary / ð Date of employee’s final paycheck:
ð Date employee will receive first paycheck: / ðDate parish/school ends contribution to insurance:
Diocesan Benefit Plan(s) Employee is Enrolled in:
(Check all that apply for term) / DOW Use:
Term:
COBRA NA E D
BC DD FLX
Life Supp Life E S D
BCBS
DD
Vested F-Yes ______% / New Hire:
H - Needs N Y
COBRA: E S
L - Needs N Y NA
A - Needs N Y NA
P - Needs N Y NA
F - Needs Waived Y NA
S - Needs Waived Y NA
Health/Dental Insurance Waived
Coverage: / Single / Family
Plan/Deductible: / $1,000 / $6,350
Life Insurance / 403(b) Pension Plan
Flex
Waived / Supplemental Life Insurance Waived
Employee Spouse Child(ren) / Flex bal ______# Mo ___ Mo $ ______
Supp Life: Emp Spouse Child(ren)
______
Parish/school representative / X
Signature / Date

Place form in your Dropbox within 5 days of hire/termination – Do Not Email

or mail/fax to: Diocese of Winona, Employee Benefits Coordinator, PO Box 588, Winona, MN 55987

Fax 507.454.8106 Questions? - Email: or call 507-858-1268 Uploaded to Dropbox

Revised 11/28/2017 Notice of New Hire or Termination