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Employee Separation Checklist

Employee Name: _____________________________________ Date of Separation: _____________________

Company Use ONLY

Complet Date Initials Item Comments
e
Separation Checklist
Employment Status Change Form
Computer, Email and Voicemail
Password Changes
Security Code Change
Notify Health carriers of Qualifying
Event for COBRA processing
Move I-9 to INACTIVE file
Update HRIS profile to INACTIVE

Employee to SIGN & RETURN (then File)

Complet Date Initials Item Comments
e
Resignation Statement (if applicable)
Reduction In Force Letter (if applicable)
Acknowledgement – Final Paycheck
Acknowledgement – Return of
Company Property
Settlement Agreement and Release of
All Claims (if applicable)
Separation Statement and
Change of Status
Acknowledgment – COBRA Rights
Acknowledgement – EDD brochures
Acknowledgement – HIPP & HIPAA
Separation Questionnaire

Employee to KEEP & READ

Complet Date Initials Item Comments
e
COBRA Notification of Rights
EDD – Unemployment Insurance
brochure
EDD – State Disability brochure
HIPP & HIPAA Notifications

43533519.docx