Employee Termination Form PDF Details

When navigating the complexities of managing workforce changes, the Employee Termination Notification Form stands out as a crucial document, especially for companies within the framework of CaliforniaCHOICE. Situated at 721 South Parker, Suite 200, Orange, CA, CaliforniaCHOICE necessitates this form for documenting significant workforce alterations such as termination of employment, reduction of hours, or even the unfortunate event of an employee's death. This form serves multiple purposes, ensuring that companies comprehensively report any employee's last working day or the cessation of their eligibility. It encompasses various scenarios including resignation, involuntary termination like layoffs or discharge for cause, and significant reductions in working hours rendering an employee ineligible for ongoing benefits. In addition to serving as a testament of these events, this document is critical for the adjustment of benefits coverage, which typically ceases at the end of the month following the employee's final eligible day. It is worth noting, failure to submit this form in a timely manner—within 30 days of the event—may affect the processing of these changes. Moreover, this form plays a pivotal role in communicating to terminated employees about their rights concerning life insurance conversion, a responsibility solely resting on the company using the services of CaliforniaCHOICE. With clear directives for submission and specific guidelines tailored towards maintaining or ceasing coverage, this form stands as an essential tool for managing employee transitions effectively, ensuring both compliance and awareness of rights and responsibilities during such critical times.

QuestionAnswer
Form NameEmployee Termination Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesemployee termination documents, cal choice employee termination form, calchoice employee termination form, ca termination notification form

Form Preview Example

721 South Parker, Suite 200 • Orange, CA 92868

(800)558-8003 • Fax (714) 558-8000 www.calchoice.com

Employee Termination

Notification Form

For Termination of Employment, Reduction of Hours, Loss of Life

Company Name

Group #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete this form when there is a termination of employment, reduction of hours or loss of life. Coverage will end on the last day of the month following each event.*

1

Employee Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Social Security Number

 

 

 

 

 

*Last Day Employed or Eligible Reason:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO

 

 

 

DAY

 

YEAR

 

 

Resignation of employment

Hours reduced - no longer eligible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Involuntary employment termination**

Deceased

2

Employee Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Social Security Number

 

 

 

 

 

*Last Day Employed or Eligible Reason:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO

 

 

 

DAY

 

YEAR

 

 

Resignation of employment

Hours reduced - no longer eligible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Involuntary employment termination**

Deceased

3

Employee Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Social Security Number

 

 

 

 

 

*Last Day Employed or Eligible Reason:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO

 

 

 

DAY

 

YEAR

 

 

Resignation of employment

Hours reduced - no longer eligible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Involuntary employment termination**

Deceased

**Involuntary termination of employment includes but is not limited to layoffs, job elimination and termination for cause.

If your company offers Life Insurance through CaliforniaCHOICE ®, it is your responsibility to notify terminated employees of their conversion rights. The life conversion information is available at www.calchoice.com.

Form MUST be signed and dated by an authorized group contact on file with CaliforniaCHOICE in order for the termination request to be processed.

Group Plan Administrator Signature

Print Name

Date

General Guidelines

•Please do not send a cancellation request prior to the actual last day of employment or eligibility

•Coverage will cease at the end of the month following the last day of employment or eligibility

•Written notification must be received within 30 days of the event

•CaliforniaCHOICE will only give retroactive credit if notification was received within the guidelines provided

•Voluntary termination of coverage for employees and/or dependents must be submitted on a change request form. (Coverage will cease at the end of the month following receipt of a completed form.)

•Dependent qualifying events should be submitted on a dependent qualifying event form. (Coverage will cease at the end of the month following the event provided written notification is given within 60 days of the qualifying event.)

This document should be faxed to CaliforniaCHOICE for immediate attention

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CC 0420A 2/2010

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This PDF form will require some specific information; to ensure accuracy, you need to take note of the recommendations down below:

1. Begin completing the cal choice termination form with a selection of essential fields. Note all of the information you need and make sure nothing is omitted!

Completing part 1 in cal choice employee termination form

2. After this part is completed, proceed to enter the suitable details in these - Employee Social Security Number, Last Day Employed or Eligible, Reason, DAY, YEAR, Resignation of employment, Hours reduced no longer eligible, Involuntary employment termination, Deceased, Involuntary termination of, If your company offers Life, Form MUST be signed and dated by, Group Plan Administrator Signature, Print Name, and Date.

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