the archdiocese of new york benefits administration resource guide

THE ARCHDIOCESE OF NEW YORK
NOTICE
CHANGE NAME OF CONTACT LISTED ON
MONTHLY INSURANCE BILLING STATEMENT
__________________________________________________________________ _______________
INSTITUTION NAME INSTITUTION #
__________________________________________________________________
STREET ADDRESS
________________________________________________________________________
CITY AND STATE
________________________________________________________________________
TELEPHONE NUMBER
________________________________________________________________________
FAX NUMBER
________________________________________________________________________
CURRENT CONTACT
________________________________________________________________________
NEW CONTACT
_________________
TITLE
_________________
TITLE
__________________________________________________________________
EFFECTIVE DATE OF CHANGE
________________________________________________________________________
SIGNATURE OF PASTOR/PRINCIPAL
________________________________________________________________________
PASTOR/PRINCIPAL PRINT NAME
________________________________________________________________________
SIGNATURE OF LOCAL ADMINISTRATOR
________________________________________________________________________
LOCAL ADMINISTRATOR PRINT NAME
_________________
DATE
_________________
DATE
_________________
DATE
_________________
DATE
SEND FORM TO:
EMPLOYEE BENEFIT CONNECTIONS
1011 FIRST AVENUE – ROOM 1679
NEW YORK, NEW YORK 10022
FAX 212.644.0690
11/2008