Employment Verification Request - Michigan



EMPLOYMENT VERIFICATION REQUESTMichigan Department of Health and Human ServicesEmployee Information: Please PrintName of Employee: FORMTEXT ?????Address:Apt #: FORMTEXT ????? FORMTEXT ?????City:StateZip Code: FORMTEXT ?????MI FORMTEXT ?????Wage and Pay Date InformationEmployee’s first date of employment:If the employee just started working, date first check will be issued: FORMTEXT ????? FORMTEXT ?????Type of Employment:Number of hours this check will include: FORMCHECKBOX Permanent FORMCHECKBOX Temporary FORMTEXT ????Number of hours expected to work (check one)Rate of PayEmployee is paid how often? FORMCHECKBOX Hourly$ FORMTEXT ????? FORMCHECKBOX Weekly FORMCHECKBOX Bi-weekly FORMCHECKBOX Per week FORMTEXT ???? FORMCHECKBOX Per pay period FORMTEXT ???? FORMCHECKBOX Salary$ FORMTEXT ????? FORMCHECKBOX Monthly FORMCHECKBOX Semi-monthlyInsurance InformationDoes the employer offer health insurance? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, when is the employee eligible to enroll?? FORMTEXT ?????What would be the expected start date? FORMTEXT ?????Has the employee accepted coverage under the health insurance plan? FORMCHECKBOX Yes FORMCHECKBOX NoWhich plan(s) will the employee be enrolled? FORMCHECKBOX Medical FORMCHECKBOX Prescription FORMCHECKBOX Dental FORMCHECKBOX VisionEmployer InformationBusiness/Company Name:Employer Contact Name: FORMTEXT ????? FORMTEXT ?????Address:Employer Title: FORMTEXT ????? FORMTEXT ?????City:State:Zip Code: FORMTEXT ????? FORMTEXT ?? FORMTEXT ?????Email:Phone Number: FORMTEXT ????? FORMTEXT ?????Signature: By signing this form, I certify the above information is true and complete to the best of my knowledge. Employer Signature:Date FORMTEXT ?????The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download