Termination of Employment
To be completed by Benefits Administrator
GENERAL INFORMATION
Participant Name:
Social Security #: - -
Last Day Worked:  
Institution/Campus:
Comments:
 
FINAL PAY INFORMATION
Final payroll end date:  
Do you anticipate future payment of salary subject to retirement? Yes      No
If "Yes": During what pay period?  
Reason for payment (e.g., retro adjustment, balance of contract):
 
CONTROL DATES
Form/Task Date Provided to Employee
ORP Group Life Conversion Notice:  
ORP Disability Conversion Notice:  
 
GIC REPORTING
I have completed GIC Form 1 for this participant: Yes      No      N/A
The participant will be a: Deferred Retiree      Retiree
 
BENEFITS ADMINISTRATOR INFORMATION
Administrator Name:
Email:
Please make sure the above email address is correct. A confirmation notice and additional instructions will be emailed to this address.
Telephone: ( ) -