Separation Notice - OCMI Workers Comp

Clients forms

SEPARATION

NOTICE

FORM

Is your employee no longer with the company or no longer needs Workers Comp insurance through your company? Complete this form to remove the employee from your Workers Comp program.

Clients forms

Workers Comp Certificate Request

Employee Onboarding

Employee Time Reporting

Recurring Payment Authorization

Client Authorization to Debit/Credit

Direct Deposit

Client Affidavit Of Zero Wages

Separation Notice

Workers Comp Claim Kit

Personal Information

Company Name

Employee Name

Important:

If this is a temporary separation or if you expect the leased employee to return to work for you, do not complete this form.

Employee Status Changes

Termination Date

Last Day Worked

Employee Termination: Required for State Unemployment Purposes

Type of Termination

Provide date and details of final incident, if any

List dates and details of any prior incidents and warnings. (attach copies of written warnings)

Please answer yes or no to the following

Question #1

Is employee eligible for re-hire with Client?

Question #2

Did employee sign a separation and release agreement?

Question #3

Upon separation did you report or will you be reporting payroll wages for the employee?

(Note: Wages must be reported to your Payroll Specialist.)

Period Covered

Period Covered Amount

I certify that my statements are true and correct

Name

Phone Number