Employee ______________________________ Date of Separation ___________________
() Resignation letter, if applicable
() Notice of dismissal, if applicable
() Lay-off notice, if applicable
() Exit Interview Questionnaire completed by employee
() Employee Reference Release and Authorization completed by employee
() Employment Verification and Reference completed by supervisor
() Property returned
- ID Card
- Calling Card
- Cell Phone
- E-mail password (change upon separation)
- Voice mail password (change upon separation)
- Other ______
- COBRA notification
- Tax-Deferred Savings Plan
- Retirement Plan
() Any earned vacation/sick time to be disbursed?
() Other (specify) _______________________________________
EMPLOYEE RESIGNATION FORM
Reason for Resignation (Please be specific): _______________________________________________________________
My last day of work will be ________________________
SAMPLE DISCHARGE LETTER
[City, State, Zip]
As you are aware, your employment with the [Operation Name] was subject to an introductory period.This introductory period, as set forth in the [Operation Name] employee handbook provided to you, was an opportunity for you to prove your abilities to satisfy the duties of the position for which you were hired – [PositionTitle]. During this period, the [Operation Name] had the ability to carefully evaluate your suitability for employment with our operation. Based on this evaluation, the [Operation Name] has determined that you have not proven your ability to satisfy the duties of the [PositionTitle] position.You have not satisfied the duties of the position for reasons that include, but are not limited to:
- Unsatisfactory performance of job responsibilities
- Inability to communicate appropriately and effectively
- Uncooperative behavior
- Failure to exhibit the requisite managerial and supervisory skills needed
- Inability to work independently
- Lack of initiative
- Inability to set deadlines
- Inability to meet deadlines as set for you by your manager
- Insubordinate behavior, in particular on the afternoon of [Date]
Accordingly, the [Operation Name] has determined that your employment with us is terminated effective [Date].You must immediately return any and all [Operation Name] property and/or information that you have in your possession or have under your control to [Name and PositionTitle]. Information obtained by you during the course of your employment with the [Operation Name] related to the business or affairs of the company are the property of the operation. Confidential [Operation Name] property and/or information may include business records, documents, memoranda, reports, financial data, customer lists, member lists, employee lists, keys, elevator key cards, space access cards, etc., regardless of whether such information is in hard copy, computer data, or recorded form.
If we do not receive such property or information by [Date], we will assume you are not in possession of any such information. However, should we later find otherwise, we will seek all measures available under applicable law.
Your salary will be paid through [Date]. Any accrued vacation and sick days you have available will be paid per [Operation Name] policy.
Your health, dental, and life insurance plans will remain in effect through [Date]. Deductions will continue at the normal amounts.Thereafter, you have certain rights to purchase insurance coverage under COBRA which are outlined in the enclosed letter. [Employee Name], if there are any other questions or concerns that you have, I would be pleased to discuss them with you.
SAMPLE SEVERANCE AGREEMENT AND RELEASE
This Severance Agreement and Release (the “Agreement”), effective _____, is entered into and between [Operation Name] and _____.
In consideration of _____ entering into this Agreement, the [OPERATION NAME] agrees to give discretionary severance pay in an amount equivalent to ______ weeks/months of (his/her) current salary (less federal and state tax deductions as required by law and other authorized deductions), to be paid in (equal installments/a lump sum) on each regular payday commencing as soon as practicable after the return of this signed Agreement. _____ acknowledges that the severance pay does not include compensation or employee benefits to which he/she is otherwise entitled. In consideration of _____ entering into this Agreement, the [OPERATION NAME] will pay the full COBRA insurance premiums for _____, medical, dental and vision plans (he/she) is currently enrolled in through the [OPERATION NAME] through _____.
In consideration of the severance pay, _____, on (his/her) own behalf and on his/her heirs, executors, administrators and assigns, hereby releases the [OPERATION NAME] and its agents, representatives, partners, employees, successors and assigns from all claims existing on or before the date of this Agreement arising from or relating to your employment or resignation and any claims which arise under the common law of contract, implied contract, tort, or statute, including (without limitation)Title VII of the Civil Rights Act of 1964, as amended, the Rehabilitation Act, the Americans with Disabilities Act, the Equal Pay Act of 1963, the Civil Rights Act of 1866 and 1971, the Age Discrimination in Employment Act, as amended, the Civil Rights Act of 1991, and the Family and Medical Leave Act of 1993. _____ further agrees to refrain from taking any action adverse to the interests of the [OPERATION NAME].
_____ acknowledges that the [OPERATION NAME] offered (him/her) twenty-one (21) days within which to deliberate the terms of this Agreement, and that the [OPERATION NAME] advised him/her to consult with legal counsel prior to executing this Agreement.
_____ acknowledges that (he/she) understands the terms of this Agreement and intends to be bound by it. _____ acknowledges that the only consideration for (his/ her) execution of this Agreement are the terms stated above; that no other promise or agreement of any kind has caused (him/her) to execute this Agreement; that the Agreement has not been obtained by any duress; and that (he/she) fully understands the meaning and intent of this document.
_____ agrees that this document and all matters leading up to or concerning this document will be regarded as privileged and confidential communications between the parties and that (he/she) will not disseminate, release, or discuss such matters by publication of any sort, in any manner or means, to any person except the members of (his/her) immediate family and (his/her) legal counsel.
_____ acknowledges that the [OPERATION NAME] advised (him/her) that during the seven (7) day period immediately following (his/her) execution of this Agreement, (he/she) may revoke it. Should _____ exercise such right of revocation, (he/she) immediately will return to the [OPERATION NAME] any consideration given to (him/her) under the terms of this Agreement._____ and the [OPERATION NAME] further agree that this Agreement becomes effective upon the expiration of the seven (7) day revocation period, provided that _____ does not exercise (his/her) right of revocation.
[Top Position Title]: _______________________________
Accepted and Agreed:
(Note: if employee is not over the age of 40, the ADEA and revocation portions must be removed.)
SAMPLE LETTER TO EMPLOYEE WHO RESIGNS
[City, State, Zip]
Dear [Employee Name],
There are some important items relating to your resignation from employment which I want to address with you.
- Your salary will be paid through your resignation date of [Date].
- According to our records, you have [Number of Hours] unused vacation hours and [Number of Hours] unused sick hours. Vacation days will be paid at your full pay rate while sick days will be paid at the rate of one-half of full pay per [Operation Name] policy.Thus, you will be paid for a total of [Number of Hours].
- The health, dental, and life insurance plans in which you are a current participant will remain in effect through [Date].Thereafter, you have certain rights to purchase insurance coverage under COBRA (please see attached letter).Your group disability coverage will terminate [Date].
- Please return any [Operation Name] property and/or information to me before [Date]. Such items may include, but are not limited to, business records and documents, keys, ID cards, company calling card, cell phone, laptop, palm pilot, email password and voice mail password.
[Employee Name], although I am disappointed to see you leave the [Operation Name], I wish you much success in your professional endeavors. Best of luck!
SAMPLE COBRA NOTIFICATION
[City, State, Zip]
Re: Notice of Right to Continue Group Health Coverage – COBRA
The health care coverage provided to you and any of your dependents by the [Operation Name] health benefit plan (the “Plan”) will end on [Date]. However, as required by the Consolidated Omnibus Budget Reconciliation Act (COBRA), you may elect to continue the health plan coverage in which you and your dependents are currently enrolled.You and your spouse should take the time to read this notice carefully. If your spouse resides at another address, please notify me immediately.
You and your spouse each have independent election rights under COBRA. For example, if you do not elect to continue medical coverage, your spouse may elect coverage for himself or herself and/or any dependent children.You or your spouse may elect coverage for any other dependent.
COBRA is available to you because coverage will terminate due to the following qualifying event (Employer: choose applicable reason and delete others):
- Your termination of employment from (includes retirement or lay-off), or a reduction of work hours with, the [Operation Name] on [Date].
- The [Operation Name] employee’s death on [Date].
- Your divorce or legal separation effective [Date].
- A dependent child ceasing to be an eligible dependent under the Plan as of [Date].
- You became enrolled for Medicare benefits on [Date].
To continue your health coverage, you must do the following:
- Prior to [Date], return your completed COBRA election form.This is within 60 days after the latter of (a) the date coverage terminates or (b) the date of this notice.
- Make your initial payment no later than 45 days following the date you return the election form.
Subsequently, you must submit your regular monthly premium in full by the first of each month.There is a 30-day grace period for these payments. If payment is not received within 30 days, coverage will be terminated back to the beginning of the period for which payment was due. Coverage cannot be reinstated.
The cost for COBRA depends on the type of benefits elected and for whom those benefits are elected.The cost of COBRA is the group Plan’s cost plus 2%. For those eligible for 29 months of COBRA, the cost will be 150% of the group Plan’s cost after the first 18 months of COBRA.The monthly cost to you for COBRA is as follows: If you choose COBRA, the Plan is required to give you coverage which, at the time coverage is being provided, is identical to the coverage provided under the Plan to similarly situated active employees or family members.
|HMO/Rx Only||[Insert applicable rates]|
|PPO Dental Only|
|Medical/Rx and Dental|
If you choose COBRA, the plan is required to give you coverage which, at the time coverage is being provided, is identical to the coverage provided under the Plan to situated active employees or family members.
1. 18 months from the date of the qualifying event if you lose coverage because of a termination of em- ployment (for reasons other than gross misconduct) or a reduction of work hours.
- Social Security Disability.The 18 months of COBRA may be extended to 29 months if you, your spouse or a dependent child are determined to be disabled by the Social Security Administration on or before the date of your qualifying event, or in the first 60 days of COBRA coverage. COBRA may be extended to 29 months for all qualified beneficiaries (see definition of “qualified beneficiary” below).
You, your spouse, or a dependent child must notify the AMA of the disability status within 60 days of the determination and within the first 18 months of COBRA coverage.The AMA must be notified within 30 days of the date the disability ends as determined by the Social Security Administration.
- Second Qualifying Events. If a second qualifying event takes place during the first 18 months of COBRA coverage, COBRA may be extended to 36 months for the former AMA employee’s spouse and children.The spouse and children must be qualified beneficiaries for the extension to apply. Second qualifying events include divorce, legal separation, death, or a dependent child ceasing to be an eligible dependent. If the second qualifying event is a divorce, legal separation or a depen- dent child ceasing to be an eligible dependent, it is the qualified beneficiary’s responsibility to notify the AMA within 60 days of the qualifying event. In no event will COBRA last beyond 36 months from the date of the original qualifying event that made you eligible for COBRA coverage.
2. 36 months from the date of the qualifying event if the original event causing the loss of coverage was the death of the employee, divorce, legal separation, the AMA employee becoming enrolled for Medi- care, or a dependent child ceasing to be a dependent child under the Plan.
The law also provides that COBRA may be terminated for any of the following reasons:
- The AMA no longer provides group health coverage to any of its employees;
- The regular monthly premium for COBRA coverage is not paid within 30 days of the date it is due;
- You become enrolled in Medicare;
- You become covered under another group health plan (as an employee or otherwise) that does not contain an exclusion or limitation that affects coverage of any pre-existing condition you may have. Effective the first day of the plan year beginning on or after July 1, 1997, a group health plan’s pre-existing condition limitation will be reduced month for month by your past continuous health coverage. An interruption in coverage of 63 days or longer eliminates this pre-existing condition credit.
At the end of the 18, 29, or 36-month COBRA coverage period, you will be allowed to enroll in an individual conversion health plan if one is offered by the Plan at that time.
Definition of a Qualified Beneficiary. Qualified beneficiaries include those covered by the Plan on the day before the qualifying event, as well as a child born to, or placed for adoption with the former employee during a period of COBRA coverage.
Open Enrollment Periods. You have the right during each open enrollment period to change your level of coverage under the Plan on the same basis as similarly situated active employees.
Adding Dependents. You may add a new dependent, spouse or child of the Plan on the same basis as similarly situated active employees.
Medicare and COBRA
- An individual may not be covered by COBRA and Medicare simultaneously.
- The AMA employee becoming enrolled for Medicare does not eliminate the spouse or dependent child’s right to COBRA.
- If the AMA employee becomes enrolled for Medicare and later terminates employment, the spouse and child who are qualified beneficiaries are entitled to the longer of 36 months of COBRA coverage from the date the employee was covered by Medicare, or 18 months of COBRA coverage from the termination date.
COBRA is offered only to comply with the requirements of federal law.Therefore, this notice should be interpreted as only providing the minimum coverage required by law.
If you have any questions about this notice or your rights to COBRA coverage, please contact me at [Phone Number].
ELECTION FORM FOR CORBRA UNDER THE [Operation Name] PLAN
I do not want to continue coverage under the Plan.
I want to continue coverage under the Plan.You may elect the type of coverage you currently have or a lesser level of coverage. I elect the following coverage (check appropriate box):
If you elected COBRA, please complete the following information about those persons (including yourself) you want covered under the Plan:
1. Is any person listed above currently employed? If so, list his/her name and the name and address of his/her employer: _____________________________________________________________________________
2. Is any person listed above currently covered by health insurance? If so, list his/her name and the name and address of the insurer: ________________________________________________________________________________
3. Is any person listed above enrolled for Medicare? If so, list his/her name: _____________________________________________________________
By signing below, I certify that all of the above information is correct. I understand that I am responsible for the premium for this coverage.The initial premium is due within 45 days of the date I sign and date this election form. I also understand that if I do not pay a regular monthly premium within 30 days of the date it is due, COBRA coverage will end as of the first day of the period for which the premium was due.
Social Security No. _____________________________
Please return this form, as well as the initial and regular monthly premium payments to:
[City, State, Zip]
EMPLOYMENT REFERENCE RELEASE AND AUTHORIZATION
I acknowledge that I have been informed that it is the [Operation Name]’s general policy to disclose in response to a prospective employer’s request only the following information about current or former employees: (1) the dates of employment, (2) descriptions of the jobs performed, and (3) salary or wage rates.
By signing this release, I am voluntarily requesting that the [Operation Name] depart from this general policy in responding to reference requests from any prospective employer that may be considering me for employment. I authorize the [Operation Name] to disclose to such prospective employers any employment-related information that the [Operation Name], in its sole discretion and judgment, may determine is appropriate to disclose, including any personal comments, evaluations, or assessments that the [Operation Name] may have about my performance or behavior as an employee.
In exchange for the [Operation Name]’s agreement to depart from its general policy and to disclose additional employment-related information pursuant to my request, I agree to release and discharge the [Operation Name] and the [Operation Name]’s successors, employees, officers, and directors for all claims, liabilities, and causes of action, know or unknown, fixed or contingent, that arise from or that are in any manner connected to the [Operation Name]’s disclosure of employment-related information to prospective employers.This release includes, but is not limited to, claims of defamation, libel, slander, negligence, or interference with contract or profession.
I acknowledge that I have carefully read and fully understand the provisions of this release. I further acknowledge that I was given the opportunity to consult with an attorney or any other individual of my choosing before signing this release and that I have decided to sign this release voluntarily and without coercion or duress by any person.
This release sets forth the entire agreement between the [Operation Name] and me, and I acknowledge that I have not relied upon any representation or statement, written or oral, not set forth in this document.
SUPERVISOR EMPLOYMENT VERIFICATION AND REFERENCE
Date of Employment _____________________________
Date of Termination _______________________________
Ending Salary __________________________
Type of Separation: () Resigned with Proper Notice () Quit without Notice () Temporary Position () Discharged for Cause
Further explanation of discharged for cause: ______________________________________________________________
What were the employee’s primary responsibilities? ________________________________________________________________________________
Explain the following:
Quality of work:
>Quantity of work:
Did this employee meet the expectations of his or her job duties? () Yes () No
Describe the content of the employee’s formal evaluations:
Is this employee eligible for rehire? () Yes () No
Supervisor’s Signature __________________________________
Supervisor’s Title _____________________________________
SUPERVISOR EMPLOYMENT VERIFICATION AND REFERENCE
Employee Name __________________________
Employment Date __________________
What prompted you to seek other employment? () Type of Work () Working Conditions () Family Circumstances () Lack of Recognition () Quality of Supervision () Better Job Opportunity () Compensation () Other (please specify)
Before making your decision to leave, did you investigate the possibility of a transfer? () Yes () No
If yes, what options were offered: ___________________________________________________
If you have accepted other employment, please complete the following:
Benefit Package __________________________
|Excellent||Above Average||Average||Below Average||Poor|
|How would you rate the following in relation to your job?|
|What is your general opinion of [Operation Name]?|
|How would you rate your job satisfaction?|
|Do you feel you were well trained for your position?|
|Do you feel there was opportunity for advancement?|
|Is the salary administration fair and equitable?|
|Is the benefit package valuable?|
|What do you think of your coworkers?|
|How effective is your direct supervisor?|
|How is your relationship with your supervisor?|
|Were you provided enough recognition for your work?|
What would you change or improve at the [Operation Name]? _____________________________________________
Was your workload usually: () varied, but okay () about right () too great () too light
Do you feel that your job was important and significant in the overall operation of the business?
Are there any particular practices or working conditions that either led to your decision to resign or that you feel are detrimental to a satisfactory working relationship? If so, have you any suggestions on how to eliminate them?
Are there any particular practices or working conditions that you feel are particularly beneficial to an effective working relationship and that should be maintained?
What did you like most about your job and the [Operation Name]?
What did you like least about your job and the [Operation Name]?
Did you feel respected as an employee?
Did you feel you were treated fairly on your performance evaluations? Why or why not?
What do others claim is the most stressful issue at the [Operation Name]? What could we do to assist them?
Would you recommend others to work at the [Operation Name]? Why or why not?
Would you care to make any other comments?
Employee Signature _____________________________
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