NCIA Insurance Agency 840 1st NE Washington, DC 20065 Tel. 202-680-7077 Fax. 202-680-7644

LIFE INSURANCE ENROLLMENT CHANGE FORM

GROUP NUMBER:		GROUP NAME:
DATE:		COMPLETED BY:	PHONE #:

PLEASE FOLLOW THE PROPER INSTRUCTIONS TO ENSURE THAT YOUR ENROLLMENT CHANGES ARE RECEIVED BY OUR OFFICE. THIS FORM IS ONLY APPROPRIATE FOR TERMINATIONS, NAME AND SALARY CHANGES. THANKS!

TERMINATE THE FOLLOWING EMPLOYEES

Employee Name	Social Security	Date Left Employment

NAME AND/OR SALARY CHANGES FOR THE FOLLOWING EMPLOYEES

Name	Social Security #	New Name	New Salary	Effective Date

Changes received in our office by the fifth of the month will be reflected on the next invoice.
For information or assistance, please call us at (202) 680-7074.