Request For Information On Termination Of Employment Page 2

Instructions for Completing the

“Request for Information on Termination of Employment”

“TO BE COMPLETED BY EMPLOYER” SECTION

1. Indicate hire date and last day of work.

2. Indicate the reason for termination.

3. Indicate if employee is eligible to be rehired. If you intend to rehire employee, indicate the

approximate date, if possible.

4. Indicate the date final check was issued, gross amount and total amount paid in the last month

of employment.

5. Indicate if employee has health care insurance coverage. If so, can former employee convert

to an individual health plan?

6. Indicate what additional benefits (i.e., severance pay, bonus check, etc.) are owed to the

employee, when they will be issued to the employee, and the balance due.

Please make sure that you sign and date the form.

SC 549-B (E/S/V) Back – 01/08

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Parent category: Business