Employee Termination Form

Please fill out the form below and click the submit button.

Employer Name *

Employee First Name *

Employee Middle Name

Employee Last Name *

Employee SS# *

Employee Date of Birth *

Employee Gender

Male Female

Employee Hire Date

Employee Mailing Address

State

City

ZIP

Termination / Qualifying Event Date *

Voluntary/Involuntary

voluntary involuntary

Employee Termination / Qualifying Event Type: Please Mark if Qualifying Event is for Employee *

Employee Termination Employee Reduction in Hours

Dependent Qualifying Event Information: Please fill in if the Qualifying event is for a Dependent

Dependent Name

Dependent Date of Birth

Dependent SS#

Relationship to Employee

Dependent Qualifying Event Type: Please mark the Type of Qualifying Event for Dependents

Death of Employee Loss of Dependent Status Employee Entitlement to Medicare Divorce/Legal Separation

FSA Plans to Remove: Please Mark all That Apply

Medical FSA Dependent Care FSA

Health Plans to Remove: Please Mark all That Apply

HRA Plan

Medical Coverage

Dental Coverage

Vision Coverage

HRA Plan Tier:

Medical Coverage Tier:

Dental Coverage Tier:

Vision Coverage Tier:

Name of Person Completing Form: *

Job Title: *

Email Address: *

Date Form Completed: *