Employment Termination Form .us
CAO NAME AND ADDRESS
CASE IDENTIFICATION
CO
RECORD NUMBER
CAT
CSLD
DIST
RECORD NAME
DATE
TO: CASE #: FROM:
Employment Termination Form
SSN: TELEPHONE #:
You have notified this office that you are no longer employed. Please have your employer complete this form and return it to the office no later than:
Favor de pedirle a su patr?n que complete y devuela este formulario a nuestra oficina antes del:
A self-addressed return envelope is enclosed or you can fax this form to:
EMPLOYER'S NAME:
EMPLOYER'S ADDRESS:
DATE EMPLOYMENT ENDED:
DID MEDICAL COVERAGE END?:
Yes No
IS EMPLOYEE ELIGIBLE FOR COBRA BENEFITS?
Yes No
GROUP/CONTRACT POLICY #:
EMPLOYER'S TELEPHONE NUMBER:
DATE OF FINAL PAY AND GROSS AMOUNT: IF YES, DATE ENDED: IF YES, NAME OF INSURANCE CARRIER: DATE COVERAGE BEGAN:
EMPLOYER SIGNATURE TITLE
DATE TELEPHONE #
PA 1898 9/13
................
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