Employee Termination Form PDF Details

The employee termination form is a document that is used to terminate an employee's employment. The form typically includes information about the employee, such as name and date of birth, as well as the reason for the termination. The form also outlines the terms of the termination, such as when payments will be made and how health benefits will be handled. Employers should ensure that they are familiar with their state's laws regarding employee terminations before terminating an employee.

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

(1 OF 1)

CC 0420A 2/2010

How to Edit Employee Termination Form Online for Free

Through the online PDF tool by FormsPal, you can easily complete or modify cal choice termination form right here. We are aimed at giving you the best possible experience with our editor by regularly releasing new features and improvements. With all of these improvements, working with our editor becomes better than ever! All it takes is a couple of easy steps:

Step 1: Hit the "Get Form" button above. It will open our pdf editor so you could start filling out your form.

Step 2: With our state-of-the-art PDF tool, you can do more than merely complete forms. Edit away and make your documents seem sublime with custom textual content put in, or fine-tune the original input to excellence - all accompanied by the capability to add stunning pictures and sign the document off.

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.

Completing section 2 in cal choice employee termination form

It is easy to get it wrong when filling out the Reason, so make sure to go through it again before you finalize the form.

Step 3: Right after you have reread the information you filled in, just click "Done" to complete your form. Join us right now and instantly get cal choice termination form, available for download. Each and every modification you make is conveniently saved , which enables you to change the document at a later stage if required. When you use FormsPal, you're able to fill out documents without the need to worry about information incidents or records getting distributed. Our secure system ensures that your private information is maintained safely.

Employee Termination Form isn’t the one you’re looking for?

Related Documents