Payroll Administration
Employee Benefits Administration
Worker's Compensation Administration
Human Resources Management
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Please fill out the form below.
Customer Name:
Employee Name:
Employee #:
Termination Date:
Quit
/
Fired
/
Layed off
Resignation Letter?
Yes /
No
Reason for termination:
Please indicate the employee's current benefits:
Medical
Voluntary Life Insurance
Dental
Dependent Life Insurance
Life Insurance
401(k)
Short/Long Term Disability
AFLAC Benefits
Vision
Payroll Instructions (severance, loans,
garnishments, unused vacation, etc.):
Final Check Instructions:
Normal Pay Circle
/
Manual Check
If Manual Provide Check Date:
Check Delivery Method:
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