Fillable Employer'S Report Of Death (Page 2 of 2) in pdf

Employer'S Report Of Death Page 2

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INSTRUCTIONS FOR REPORTING AN EMPLOYEE DEATH

„ Part A – Member Information

1-5. Enter the indicated personal information about the employee.

6. Enter the date the employee became a Retirement System member.

7. Enter the last day the employee was physically at work.

8. Enter the last day for which the employee was compensated, including sick and annual leave. The last day on

payroll cannot be later than the date of death.

9. If the last day physically at work (Part A, #7) and the last day on payroll (Part A, #8) are different, please ex-

plain the reason for the difference.

10. Enter the employee’s date of death.

11. If the death was the result of an on-the-job accident as defined in K.S.A. 74-4916(a), please briefly describe

what the employee was doing and how the accident happened. The Retirement System also requires a copy of

the workers’ compensation death report and a notarized affidavit from the employee’s supervisor stating that

the employee was performing job duties when the death occurred.

„ Part B – Compensation and Contribution Information

1. Enter the total compensation earned in the 12-month period immediately before the month the employee was

last on payroll. Always use the first day of the month to begin the 12-month calculation. Note: Do not include

workers’ compensation pay.

To calculate the 12-month period, count from the month before the date the employee was last on your payroll

(Part A, #8). For example, if the employee’s last day on payroll was 6/25/14, report actual earnings for the days

worked from 6/1/13 through 5/31/14.

2. Enter the rate of pay at the time the employee left active employment. Multiply the employee’s hourly rate of

pay by the number of hours the position required per year. Note: Do not include longevity pay.

3. If there is more than $2,500 difference between the employee’s total compensation (Part B, #1) and the current

annual rate of pay (Part B, #2), please explain the reason for the difference.

„ Part C – Employer Certification

1. Enter the name of the participating employer.

2. Enter the employer’s (4) four-digit identification number.

3. The Retirement System will accept only the designated agent’s signature on file or an authorized representa-

tive whose signature is also on file.

Employer'S Report Of Death Page 2

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