| Personal Information
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| *indicates required fields
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| *Full Name:
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| *Last 4-digits of your SSN:
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*Address:
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*Phone Number:
*Date of Birth:
Format: MM/DD/YYYY
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| E-mail Address:
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| Please re-enter your E-mail Address for confirmation:
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| *Employment Status:
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Current Employee
Former Employee
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| Beneficiary Information
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| Beneficiary Name:
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Date of Birth:
Format: MM/DD/YYYY
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Single
Married
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| Estimate Request
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Please send me an estimate of the value of my LUERP account as of:
Current Date
Future Date**
**If you selected "Future Date" above, please list specific date(s) below in order to determine the estimated value of your LUERP account.
Date Format: MM/DD/YYYY
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Send estimate(s) to:
My home address
My e-mail address
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| Signature/Authorization |
*By checking this box, I authorize the Human Resources department to perform any steps that are needed to fullfil this request.
*Date Signed:
Format: MM/DD/YYYY
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For questions, please contact Dave Siembal at 312.915.7209 or dsiemba@luc.edu.
For information about LUERP, visit LUC.edu/hr/luerp.shtml.
PLEASE ALLOW 2 WEEKS FOR PROCESSING
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