HTML Preview Printable Employee Termination Form page number 1.
CoPower • 1600 W. Hillsdale Blvd., San Mateo, CA 94402 • Phone: 888.920.2322 • Fax: 650.348.1149 • E-mail: [email protected]
CPF-010 5/12
Employee Termination Form
To be filled out by the Benefits Administrator - (CoPower ONE, CoPower SUITE, and CoPower OPTIONS)
Please fill out completely and submit to CoPower within 14 days of termination. If CoPower does not receive
timely termination information, the employer is responsible for all premiums and fees due for timeframes
outside of this 14 day window.
Employer Information
Company/Group Name:
Group Contact Person:
CoPower ID#:
Contact E-mail:
Contact Phone Number:
Date:
Employee Termination Information
Employee Name (last, first):
Social Security Number:
Qualifying Event Date/Last Date of Employment:
Mailing Address (Mandatory for Cal-COBRA Groups):
City:
State:
Zip:
Reason for Termination
Voluntary termination of employment
Obtained other coverage or covered through spouse
Voluntary termination of coverage
Involuntary termination of employment
Reduction of hours
Leave of absence or medical leave
Divorce
Deceased (provide date of death)
Expired COBRA coverage
Enrolled in error
Gross Misconduct (not COBRA eligible)
Group Open Enrollment
Other (please explain below)
Comments (if “Other” please explain):
Plan coverage to terminate:
CoPower ONE* Dental Vision Basic Term Life and AD&D* Voluntary Life and AD&D*
*Life and AD&D benefits are not COBRA eligible. Employer is responsible for communicating conversion and portability options to the
terminated employee, if applicable to your plan.
Life and AD&D coverage requires 100% participation for Unum and MetLife plans and employee should not be terminated from Life
coverage if the employee is currently an active full time employee of the group.
FED COBRA (Mandatory for groups subject to Fed-COBRA only)
Employee has elected Fed-COBRA
Employee has NOT elected Fed-COBRA
(employee is still in election period or has declined
election)
COBRA INFORMATION
Determination
Administration
Fed-COBRA
If your company employed 20 or more
employees for the majority of the last calendar
year.
Benefits must be administered by the employer. If employee has
declined Fed-COBRA benefits OR you are not yet sure whether they
want the benefits, check “Employee has not elected Fed-COBRA.”
Employee has 60 days to elect coverage at which time a
reinstatement should be faxed to CoPower.
Cal-COBRA
If your company employed 19 or less employees
for the majority of the last calendar year.
Benefits will be administered by CoPower if employee elects.
Please provide us with the employee’s mailing address and we
will mail the necessary paperwork.