Faxed to: "Caseworker's Name"
The following information is provided in response to your request on: 7/6/2008
The employer provided this information to The Work Number to act as their official agent for employment and income verification. Any inconsistency between the most recent start date and the total time with the employer is due to prior work period. If you have any questions, please call our Client Service Center at 1-800-996-7566 (Voice) / 1-800-424-0253 (TTY/Deaf).
Information not provided by the employer is shown as "Data Not Provided." Employment and Income information current as of
12/16/1899
Reference Number for this verification: 10639911 |
EMPLOYER |
| Employer: |
90001 - Enterprise Test Co. |
| Employer Headquarters Address: |
2234 Main Street |
| |
St. Louis, MO 63146 |
| Federal Employer Identification Number (FEIN): |
123456789 |
EMPLOYEE |
| Employee: |
Randy W. Doe |
| Social Security Number: |
111-00-3341 |
| Address: |
1545 Orangedale Lane |
| |
St. Louis, MO 63122 |
| Date of Birth: |
12/03/62 |
EMPLOYMENT |
| Employment Status: |
Active |
| Most Recent Start Date: |
2/01/99 |
| Original Hire Date: |
2/1/99 |
| Total Time with Employer: |
3 years, 6 months |
| Job Title: |
Clerk |
| Union Affiliation: |
None |
| Work Location (Job Site): |
1850 Borman Court |
| |
St. Louis, MO 63146 |
* MEDICAL INSURANCE |
| Medical Insurance Available: |
Yes |
| Employee Eligible: |
Yes |
| Reason for Ineligibility: |
None |
| Employee Enrolled: |
Yes |
| Eligibility Date: |
5/01/99 |
| Coverage Start Date: |
5/01/99 |
| Coverage Termination Date: |
Data Not Provided |
| Medical Carrier Name: |
United Healthcare |
| Medical Carrier Address: |
Data Not Provided |
| Medical Carrier Phone Number: |
314-214-7000 |
| Medical Insurance Policy Number: |
111-00-3341-01 |
| Medical Carrier Group Number: |
GN-0098 |
| Coverage Level: |
Data Not Provided |
| Annual Cost for Medical Insurance: |
Data Not Provided |
| Dependent Coverage Available: |
Yes |
| Per Pay Period Cost to Add Dependent: |
$10 |
| Number of Dependents Covered: |
2 |
| Dependents Covered: |
2 |
| Dependents |
SSN |
Birth Date |
| John R. Doe |
111-00-3341 |
03/04/95 |
| Suzie M. Doe |
842-00-2237 |
11/27/98 |
|
Participating in Medical COBRA: |
Data Not Provided |
* DENTAL INSURANCE |
| Dental Insurance Available: |
YES |
| Employee Eligible: |
YES |
| Employee Enrolled: |
YES |
| Dental Carrier Name: |
Delta Dental |
| Dental Carrier Phone Number: |
314-214-7000 |
| Dental Insurance Policy Number: |
1023345 |
* VISION INSURANCE |
| Vision Insurance Available: |
YES |
| Employee Eligible: |
YES |
| Employee Enrolled: |
NO |
| Dental Carrier Name: |
Data Not Provided |
| Dental Carrier Phone Number: |
Data Not Provided |
| Dental Insurance Policy Number: |
Data Not Provided |
* WORKERS' COMPENSATION |
| Receiving Workers' Compensation: |
Yes |
| Carrier: |
GatesMcDonald |
| Date of Injury: |
2/22/01 |
| Date of Award: |
6/05/01 |
| Claim Number: |
12345 |
| Claim Pending: |
No |
INCOME AND DEDUCTIONS |
| Average Hours per Pay Period: |
80 |
| Rate of Pay: |
$9.00 hourly |
| |
2002 |
2001 |
2000 |
| Total Gross: |
9,850.00 |
18,150.00 |
18,150.00 |
| Payroll Deduction For All Insurance Coverage: |
|
|
40.00 |
|
PAY PERIOD DETAIL
12/16/1899
|
| Income |
Withholding |
| Total Gross Earnings |
720.00 |
Federal Tax |
108.90 |
| Pension |
0.00 |
State Tax |
25.40 |
| Other Income |
0.00 |
Local Taxes |
11.40 |
| |
|
State Tax |
25.40 |
| |
|
Social Security |
43.20 |
| |
|
Medicare |
9.42 |
| |
|
Retirement / 401K |
40.00 |
| |
|
Cafeteria Plan |
10.50 |
| |
|
Garnishments |
0.00 |
| |
|
Other Withholding |
0.00 |
| |
|
Net |
514.38 |
|
| Pay Pd. Date |
Pay Date |
Hours Wkd. |
Gross |
Net |
| 12/16/1899 |
12/20/1899 |
80.00 |
720.00 |
514.38 |
| 12/2/1899 |
12/5/1899 |
80.00 |
720.00 |
514.38 |
| 11/18/1899 |
11/21/1899 |
80.00 |
720.00 |
514.38 |
| 11/4/1899 |
11/7/1899 |
60.00 |
540.00 |
383.40 |
| 10/21/1899 |
10/24/1899 |
80.00 |
720.00 |
514.38 |
| 10/7/1899 |
10/10/1899 |
70.00 |
630.00 |
447.30 |
|
* Please note that medical, dental, vision, and workers' compensation benefits are provided in some but not most verifications. |
