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Clients forms




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.

Personal Information


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


Employee Termination: Required for State Unemployment Purposes

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.)

I certify that my statements are true and correct