FW: Macrosoft Insurance Coversion for an Ex employee

["Tabata Figueroa (ARREDONDO)" <http://www.macrosoft.com/~tabataa>]

Robert - the Benefits team can assist you with this directly.

Thanks
Tabata

From: Aarti Dewan
Sent: Friday, May 25, 2012 11:46 AM
To: Tabata Figueroa (ARREDONDO)
Subject: Macrosoft Insurance Coversion for an Ex employee

Hi Tabata,

I am doing this on behalf of an ex-employee - Robert.

He needs the form (attached) filled out to convert his Long Term Disability 
Insurance. The filled form can be emailed to him(Robert 
http://dummy.us.eu.org/robert<http://dummy.us.eu.org/robert>) or faxed to him at  
my-2012-fax-number.

Are you the right person or should he be contacting someonelse?

Thanks!
Aarti
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 Robert â?? the Benefits team can assist you with this directly.

 Thanks

 Tabata

 From: Aarti Dewan
 Sent: Friday, May 25, 2012 11:46 AM
 To: Tabata Figueroa (ARREDONDO)
 Subject: Macrosoft Insurance Coversion for an Ex employee

 Hi Tabata,

 I am doing this on behalf of an ex-employee â?? Robert.

 He needs the form (attached) filled out to convert his Long Term Disability 
 Insurance. The filled form can be emailed to him(Robert 
 http://dummy.us.eu.org/robert ,http://dummy.us.eu.org/robert, ) or faxed to him at  
 my-2012-fax-number.

 Are you the right person or should he be contacting someonelse?

 Thanks!

 Aarti

Employer Statement
1 Employer
Information

Name of Employer
Control Number

Branch

Employee First Name

MI

Employee Last Name

Social Security Number

2 Coverage
Information

Coverage is being terminated due to:
Disability

Employment Terminated

Retirement

Date coverage began under a
Group Plan (MM DD YYYY)

Date coverage terminated under
the Group Plan (MM DD YYYY)

Leave of Absence

No longer a member of an employee class
eligible for Group LTD coverage

Employment termination date (MM DD YYYY)

Other____________________________
Was the employee covered under your LTD plan (present plan or
combination of present and prior plans) for 12 months or more?

3
Employment
Information

No

Note to Employer: Please attach a current job description and veri�cation of 
salary.
Monthly earnings at date of termination

Employeeâ??s Occupation

.

$
4 Plan
Information

Yes

Scheduled Monthly Bene�t under the
Group LTD Plan (e.g., 40%, 50%, 60%, 66 2/3%)

.

% Maximum monthly bene�t $

Name of Employer Contact
Employer Address
Street
City

State

Employer Contact Telephone

ZIP Code

Extension

The information provided is correct and complete to the best of my knowledge.
Date (MM DD YYYY)
Signature

X

Prudential and the Rock logo are registered service marks of The Prudential 
Insurance Company of America
and its af�liates.
GL.2007.188

Ed. 0807

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