Indiana Health Care Services
(800) 260-6145
Franchise
(800) 953-6183
info@signalhg.com
info@signalhg.com
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Employee Consent for Insurance Verification
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Employee Consent for Insurance Verification
Employee Consent for Insurance Verification
Print Employee Name
Employee Signature
Company Contacted
Mr./Mrs
is seeking employment with our company. It is our policy to ask for references prior to employment. Please complete this form for our records and sign below. We would greatly appreciate your assistance.
PLEASE VERIFY EMPLOYMENT DATES:
From:
To
ELIGIBLE FOR REHIRE?
YES/NO
COMMENTS:
Information received by: Phone Mail Fax
Signature of Agency
From:
To
