Employee Separation From Service Form

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EMPLOYEE SEPARATION FROM SERVICE
FORM
UPON RECEIPT OF “NOTICE “SUBMIT FORM TO HUMAN RESOURCES IMMEDIATELY
MUST
MANAGER OR DESIGNEE
COMPLETE THIS SECTION
EMPLOYEE NAME: ___________________________________________________________________________
DEPARTMENT/ POSITION: _____________________________________________________________________
NOTICE OF RESIGNATION ATTACHED ____________
DATE OF SEPARATION:________________________________________________________________________
MUST
REASON FOR LEAVING/COMMENTS--------- YOU
STATE VOLUNTARY OR INVOLUNTARY & REASON
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Voluntary (personal, retirement, moving, new job) Involuntary (Layoff, contract not renewed/contract ended, discharge – BE SPECIFIC
CIRCLE ONE:
Eligible for rehire
Ineligible for rehire
Collected agency property (check or write N/A) ___ laptop ___ cell phone ___ keys/key cards ___ badge
------------------------------------------------------------------------------------------------------------------------------------------------------------
-
HUMAN RESOURCES COMPLETES SECTION BELOW
FINAL CHECK DATE: ________________________
______
PAYROLL & HR FILES COMBINED
TERM LETTER SENT w/ unemployment info & exit form
______
______UPDATED STATUS IN HRDB
BENEFITS (20+ HRS/WK)
NOTIFY THE FOLLOWING
END CES LIFE ___ REMOVED FROM BILLING SHEET
___PAYROLL DEPT
END MEDICAL ___ ON-LINE IF APPLICABLE
___ACCT PAYABLE
END DENTAL___ ON-LINE IF APPLICABLE
___TECHNOLOGY
END FSA ___ E-MAIL ABG (COBRA ELIGIBLE?)
___COMMUNICATIONS (LUCIA)
END STD ___ NOTE ON CURRENT BILL
___RECEPTIONIST
END VLIFE ___ NOTE ON CURRENT BILL
___FACILITIES/SECURITY/PHONE (KIM)
BENEFITS’ ADJUSTMENT WORKSHEET ___
____UPDATED STATUS IN HRDB
CREATED COBRA RECORD ___
____OBRA? – TERM IN GREATWEST
457 PLAN? NOTIFY GREATWEST ___

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