Form K-Ben 3109 - Employer'S Separation Statement Form - Kansas Department Of Labor
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2KANSAS DEPARTMENT OF LABOR
Page 1 of 2
For Office Use Only:
EMPLOYER’S SEPARATION STATEMENT
K-BEN 3109 Web (Rev. 2-14)
INSTRUCTIONS: Complete all information related to the separation, sign and return this form
with the Employer Notice, K-Ben 44/45. You MUST sign both documents. Attach supporting
documentation, i.e., written warnings, company policies, medical statements, etc.
Failure to submit complete information shall bar you from protesting any
subsequent decision made regarding this claim (K.S.A. 44-709(b)). The information
provided will be used to determine if benefits should be paid and if your account will be
charged as a base period employer. A determination will be mailed to you at a later date.
Claimant name: _________________________________________________________ Social Security number: ____________________
Business name: __________________________________________________________________________________________________
I do not wish to protest this claim or provide any separation information.
LEAVE OF ABSENCE: Complete if the reason for separation was leave of absence. Include a copy of claimant’s written request
for a leave of absence and any other supporting documentation, including the company’s policy regarding leave of absence
.
Date leave began (mm/dd/yyyy): ____________________________ Date leave will end (mm/dd/yyyy): ____________________________
If no definite return date, explain: ____________________________________________________________________________________
_______________________________________________________________________________________________________________
Did claimant request the leave or was this leave mandatory? Explain, including reason for leave: _________________________________
_______________________________________________________________________________________________________________
DISCHARGED: Complete if the reason for separation was discharge. If more space is needed, attach additional sheets. Include
supporting documents, i.e., copies of written warnings, copy of policy(s) and/or employee’s written acknowledgement of company
policy.
Name and title of who discharged claimant: ____________________________________________________________________________
Reason claimant was given for discharge: _____________________________________________________________________________
_______________________________________________________________________________________________________________
Final incident that led to claimant’s discharge, explain in detail: _____________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Was the claimant discharged due to a violation of company policy?
YES
NO
If YES, what policy was violated?
(Attach a copy of policy violated.) __________________________________________________________________________________
_______________________________________________________________________________________________________________
Was the claimant given any verbal warnings?
YES
NO
Written warnings?
YES
NO
If YES, provide dates and reasons (Attach a copy of each warning.): ______________________________________________________
_______________________________________________________________________________________________________________
How was the claimant made aware of the policy (written policy, company handbook, etc.)? _______________________________________
Was claimant discharged due to absenteeism?
YES
NO
Was claimant given any written warnings?
YES
NO
If YES, provide dates and reasons for absences (Attach a copy of each warning.): ___________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Do you have a written policy regarding attendance/absenteeism?
YES
NO
(If YES, provide a copy of the specific policy that relates to this separation.)
continued on next page
KANSAS UNEMPLOYMENT CONTACT CENTER
Kansas City Area (913) 596-3500 • Topeka Area (785) 575-1460 • Wichita Area (316) 383-9947 • All Other Areas (800) 292-6333
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