Employee Separation Report

INSURANCE EMPLOYEE SEPARATION REPORT

Diocesan Entity ______SP#______EMP #______

City ______Phone # ______

Employee Name ______SS# ______

Address, City ______Phone # ______

Occupation ______Date Hired ______Last Day Worked ______

(last day physically at work)

Reason for Separation:

Explanation: ______

1. Retiring? ______Date of Retirement ______This must be the day immediately following

Yes No the last day worked noted above

1.a. Receiving Diocesan Pension right after last day of work? ______

Yes No

2. Is the employee immediately covered by other health insurance? ______

Yes No

·  If not, Diocesan health insurance will continue for two full months beyond the month of termination. Employee is responsible for the contributory premiums for these two month and this will be withheld from the final paycheck _____*(Employee Must Initial)

·  If you elect to extend your coverage for the additional 2 full months, do you also wish to continue health coverage for your dependents by paying the premium to the entity during these two months?

YES____ NO_____ Employee is responsible for the contributory premiums for these two month and this will be withheld from the final paycheck _____* (Employee Must Initial)

3. Is the employee currently participating in the Diocesan FSA or FSAD plan? ______

·  If the employee is currently participating in the flexible spending plan for health or dependent care, there are strict regulations about the availability of those funds for separating employees. The employee should contact the Diocesan Benefits Office for more information. ______* (Employee Must Initial)

4. All voluntary or optional benefits terminate as of the last day worked. Employees enrolled in Colonial products will be contacted by Colonial and asked if they would like to set up a direct relationship with the carrier to continue the coverage. All employee who wish to continue basic or voluntary life insurance through The Hartford, please contact: Lisa Baggett, in The Diocese of St. Petersburg Benefits Office, at 727-344-1611. ext. 5397 for information.

5. If vested (5 years) in the Diocesan Pension Plan, Employer and Employee please at this time complete an “Application

for Retirement, Vested Termination or Disability Benefits,” and send it to the Plan Administrators: Gabriel, Roeder,

Smith & Co., ATTN: Susan Gigler, One East Broward Boulevard., Suite 505, Ft. Lauderdale, FL 33301.

Phone # (954) 527-1616, FAX (954) 525-0083.

______* ______

Employer Signature Employee Signature

Date ______Date ______

THIS FORM MUST BE COMPLETED UPON SEPARATION OF ANY Benefits Eligible AND MAILED TO:

Catholic Diocese of St. Petersburg

Benefits Office

Post Office Box 40200

St. Petersburg, FL 33743-0200 (revised 5-29-14)