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Employee
name:
Position:
Date
of hire:
Date of termination:
Topics
To Discuss:
____
Salary/Payroll
Salary through last day of employment:
Accrued, unused vacation
through last day:
Other adjustments (commission, travel expenses, etc.)
____
Disclose any benefits included as taxable wages
Total of final paycheck:
____
Employee benefits:
Health Insurance:
____ COBRA information
given to employee
Date coverage ends:
Reimbursement due employee for premium:
____ Insurance company
notified
Life Insurance:
Date coverage
ends:
____ Insurance company notified
401(k) Plan:
____ Withdrawal/Rollover information given to employee
Profit Sharing Plan:
____ Employee notified of
any distribution
____
Completion of Exit Interview
Return
of Company Property:
____
Identification badge
____
Keys and key cards
____
Equipment (Laptop PC, pager, cell phone, tools, etc.)
____
Credit cards
____
Business Car
____
Books and other printed material
____
Other items, list:
The
terminating employee's forwarding address:
Completed
by:
Name:
Position:
Date: