Employment Separation Form

Please complete and submit this form for each separated employee.

Employer Name:
Separated Employee's Full Name:
Last Four of Employee's Social Security Number:
Date of Separation/Last Day Worked:
Reason for Separation:
Eligible for Rehire (Yes or No):

Supervisor Name:
Name and Title of Person Submitting this Update:


*Please note:

  • was the member laid off?
  • did the member quit?
  • was the member terminated?