HTML Preview Sample Employee Termination Request Form page number 1.
1102-146 DB (R11-13)
Retirement Plan Services
P.O. Box 2978 • 5910 Mineral Point Road
Madison, WI 53701-2978
Phone: 800.999.8786 • Fax: 608.236.7395
www.benefitsforyou.com
EMPLOYEE TERMINATION REQUEST
DEFINED BENEFIT RETIREMENT PLAN
TYPE OF BENEFIT REQUESTING
Actual benefit calculation requested (check reason for leaving below):
Termination Retirement Total and Permanent Disability
Death (include copy of death certificate)
Use online Beneficiary Election for the death benefit. (If this box is not selected, please attach most recent
beneficiary designation form.)
Estimated benefit calculation requested (submit a separate form for each estimated date or estimated age)
EMPLOYER INFORMATION
Employer Name
State Employer Contract Number (8 digit) Plan Number
001 002 022 Other
EMPLOYEE INFORMATION
Employee Name Date of Birth
/ /
Social Security Number
– –
Termination Date
/ /
Home Address Street City State Zip
Rehire Date (if applicable)
/ /
Marital Status
Single Married
Spouse’s Name Spouse’s Date of Birth
/ /
Phone Number (optional)
( )
HOURS OF SERVICE (for Vesting)
Enter the following dates. Then, determine if the employee worked more or less than 1,000 hours during these time frames:
Under 500 hours 500-999 hours 1,000 hours or more
Through
Hire Date Plan Anniversary Following Hire Date
Through
Last Plan Anniversary Date Termination Date
These hours should include paid vacation and sick leave up to 501 hours. We will assume the employee
worked 1,000 hours or more in each full plan year between the above dates unless otherwise noted on a
separate sheet attached to this form.
SALARY
Enter the total includable compensation* earned during the highest consecutive 60 (or 36) months of service as defined in your plan.
60 months 36 months
Compensation from / / through / /
( months) ( months) $
Compensation for the entire plan year of ( 12 months) ( 12 months) $
Compensation for the entire plan year of ( 12 months) ( 12 months) $
Compensation for the entire plan year of ( 12 months) $
Compensation for the entire plan year of ( 12 months) $
Compensation from / / through / / ( months) ( months) $
*Please refer to the definition of compensation in your Plan document.
EMPLOYEE CONTRIBUTIONS (if applicable)
Enter contributions made by employee from last plan anniversary date to date of termination:
• Employee Contributions: $
PLAN ADMINISTRATOR SIGNATURE RETURN TO
I, as Plan Administrator, verify that the above information is correct.
Signature:
X
Date
ATTN Retirement Plan Services
CUNA Mutual Group
PO Box 2978
Madison WI 53701-2978