Your Company Name Here

Employee Termination Checklist

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:
Date coverage ends:
 COBRA information given to employee
 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
____ For Your Benefits/Workers’ Compensation Notice/SDI/Paid Family Leave Notice
____ Change of Status Notice
Return of Company Property:
____ Identification badge
____ Keys and key cards
____ Equipment (Laptop PC, pager, cell phone, tools, etc.)
____ Credit cards
____ Books and other printed material
____ Other items, list:

The terminating employee's forwarding address:

I do not have any knowledge of any activities such as harassment, Workers’ Compensation injuries or any other
illegal or unlawful activities happening at (insert Company name). I acknowledge receipt of the above forms.

Terminating Employee’s Signature Date Signed

Print Name: Position held:

HR Representative: Date: