Fillable 2015 Termination Form printable pdf download

McDonald’s Licensees Health & Welfare Plan

Association / Company #_______________________________________

Ronald McDonald House Charities Health & Welfare Plan

(Located on monthly invoice)

2015 Termination Form

ENROLLMENT ADMIINISTRATOR (MERCER) USE ONLY:

1. EMPLOYEE INFORMATION

SSN:

Name (Last):

Name (First):

MI:

Previous Name (if applicable):

Phone Number:

Home

Mobile

Address:

Apt. / Suite #:

City:

State:

ZIP Code:

E-mail Address:

2. VOLUNTARY TERMINATION OF BENEFITS (EMPLOYEE SIGNATURE REQUIRED IN SECTION 6)

Applies only to Employees who are still employed but elect to voluntarily terminate all benefits.

Voluntary Termination of Benefits

Coverage will be terminated the last business day of the month in which the form is received by Mercer.

Note: Employees who voluntarily terminate their coverage while maintaining employment and/or eligibility are not eligible for COBRA coverage.

Employees who are only terminating some of their benefits should use the Enrollment / Change Form.

3. TERMINATION OF EMPLOYMENT / ELIGIBILITY REASON (DATE REQUIRED)

You must submit a completed Termination Form

within five (5) business days of the event listed

below. Requests received after five (5) business days will be processed

effective the last day of the month in which the request is received by Mercer on behalf of the Plan:

Please select only one reason / event:

LAST DAY WORKED OR EVENT DATE (REQUIRED):

Employee Voluntarily Terminated Employment

Job Abandonment

Employer Notes:

Employment Terminated (non-gross misconduct)

Employment Terminated (gross misconduct) **

Reduction of Hours

Demotion – New Job Classification:

Store Sale

Death of Employee

Medicare Eligible

FMLA Expired*

Leave of Absence* (after 90 days)

*Medical, Dental and/or Vision coverage must be terminated after ninety (90) days not actively at work regardless of the reason for absence.

**Gross misconduct may be defined as intentional, wanton, willful, deliberate, reckless or engaging in deliberate, possibly criminal (such as stealing, harassment or work place

violation) acts that may justify the immediate dismissal of an employee.

Keep Optional Benefits Active:

Yes

No Available only if termination is due to Leave of Absence or FMLA Expiration.

Optional benefits include only life and disability insurance

4. TERMINATION OF SPOUSE / DEPENDENT

Dependent Reached Maximum Age

Divorce / Legal Separation (attach proof of divorce / legal separation court documents)***

***To update your beneficiary designation, please complete an Enrollment / Change Form.

Termination of Domestic Partnership****

****The Notice of Termination of Domestic Partnership Form must also be completed separately.

5. LIST ALL DEPENDENT FAMILY MEMBERS TO BE TERMINATED (COMPLETE IF TERMINATING DEPENDENTS ONLY)

Dependent name

Address

City

State

ZIP Code

Dependent name

Address

City

State

ZIP Code

6. EMPLOYEE SIGNATURE (ONLY REQUIRED FOR VOLUNTARY TERMINATION OF ALL BENEFITS)

Employee Signature

Date

7. EMPLOYER SIGNATURE (REQUIRED)

Employer Signature

Date

Phone:

Office

Mobile

E-mail:

EMPLOYER:

KEEP A COPY OF THIS FORM ALONG WITH PROOF OF SUBMISSION FOR YOUR RECORDS.

Send completed form by:

Fax: 1-319-887-4114

E-mail:

Mail: McDonald’s Licensees & RMHC Health & Welfare Plans P.O. Box 4548 Iowa City, IA 52244-4548

It is not necessary to mail in a faxed or e-mailed form.

Revised 08/2014

2015 Termination Form

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