Separation notice

Important: If this is a temporary separation or if you expect the leased employee to return to work for you, do not complete this form.

Personal Information

Company Name

Employee Name

Employee Status Changes

Termination Date

Last Day Workerd

Employee Termination: Required for State Unemployment Purposes

Type of Termination (Choose one)

Provide date and details of final incident, if any

List dates and details of any prior incidents and warnings

Any additional instructions or request?

attach copies of written warnings

Upload a file

Please answer YES or NO to the following

Is employee eligible for re-hire with Client?

Yes

Did employee sign a separation and release agreement?

Yes

Upon separation did you report or will you be reporting payroll wages for the employee?

Yes

What type of pay the employee will be receiving?

(Note: Wages must be reported to your Payroll Specialist.)

Period Covered

Amount

. I certify that my statements are true and correct

Authorized Representative

Date

Phone Number