Form K-Ben 3109 - Employer'S Separation Statement Form - Kansas Department Of Labor Page 2
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2Kansas Department of Labor
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Employer’s Separation Statement
K-BEN 3109 Web (Rev. 2-14)
Claimant name:
Social Security number:
Was claimant given written notice that future absence may or will result in discharge?
YES
NO
If YES, dates: ___________________________________________________________________________________________________
Was claimant discharged because of the use or sale of alcohol or drugs on the job?
YES
NO
If YES, what caused you to suspect the use or sale of alcohol or drugs on the job? _____________________________________________
_______________________________________________________________________________________________________________
Is there proof relating to the incident (witnesses, signed statement, charges filed, police reports, test results, etc.)?
YES
NO
(If YES, provide copy of proof.)
Did claimant fail or refuse to submit to a chemical or breath alcohol test required by law?
YES
NO
If YES, state law and explain: _______________________________________________________________________________________
_______________________________________________________________________________________________________________
Did claimant fail or refuse to submit to a chemical or breath alcohol test pursuant to an employee assistance program or other drug or
alcohol treatment program the claimant was participating in?
YES
NO
If YES, explain: _______________________________
_______________________________________________________________________________________________________________
Was the test a required condition of employment for the claimant’s job?
YES
NO
QUIT: Complete if the reason for separation was resignation. If more space is needed, attach additional sheets. Include
supporting documents, i.e., copy of written resignation or notice of intent to leave.
Did the claimant give notice of leaving?
YES
NO
If YES, effective date of resignation: _______________________________
Reason claimant gave for quitting: ___________________________________________________________________________________
Did claimant request a job transfer prior to leaving?
YES
NO
Was one available?
YES
NO
Explain: ________________________________________________________________________________________________________
Did claimant quit because of medical reasons?
YES
NO
Did claimant give medical proof of inability to perform regular duties?
YES
NO
If YES, explain: __________________________________________________________________________________________________
Was work available within the claimant’s medical restrictions?
YES
NO
If YES, was the claimant offered this work?
YES
NO
Did the claimant accept this work?
YES
NO
Explain: ________________________________________________________________________________________________________
TEMPORARY AGENCY: If you are a temporary agency that provides temporary employees, complete the following:
Did the claimant complete the last assignment?
YES
NO
If YES, did the claimant contact you and request another assignment?
YES
NO
If YES, date claimant contacted your office: _____________________________ (Provide a copy of the written policy about requesting
an additional assignment after the completion of one and the signed claimant’s acknowledgement of this policy.)
ADDITIONAL COMMENTS REGARDING SEPARATION: _____________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
CERTIFICATION: I certify that the information I have provided is correct and complete and I understand the willful or
intentional misrepresentation or failure to disclose a material fact is punishable under the Kansas Employment Security Law.
Signature: _________________________________________________
Date: _______________________________________________
Printed name: ______________________________________________
Title: _______________________________________________
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Phone: ___________________________________________________
Fax: ________________________________________________
Email: _________________________________________________________________________________________________________
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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