Office Telephone

Employment Termination Form

TO:

CASE #: SSN:

FROM: TELEPHONE #:

You have notified this office that you are no longer employed. Please have your employer complete this form and return it to the office no later than:

Favor de pedirle a su patrón que complete y devuela este formulario a nuestra oficina antes del: A self-addressed return envelope is enclosed or you can fax this form to: EMPLOYER’S NAME: EMPLOYER’S TELEPHONE NUMBER:

EMPLOYER’S ADDRESS:

DATE EMPLOYMENT ENDED: DATE OF FINAL PAY AND GROSS AMOUNT: DID MEDICAL COVERAGE END?:

Yes No

IF YES, DATE ENDED:

IS EMPLOYEE ELIGIBLE FOR COBRA BENEFITS?

Yes No

IF YES, NAME OF INSURANCE CARRIER:

GROUP/CONTRACT POLICY #: DATE COVERAGE BEGAN:

EMPLOYER SIGNATURE DATE

TITLE TELEPHONE #

PA 1898 3/13

CAO NAME AND ADDRESS CASE IDENTIFICATION

CO RECORD NUMBER CAT CSLD DIST

RECORD NAME DATE

Contact this candidate