Integrity | Employee Worksite Termination

Employee Worksite Termination Form

Pursuant to Texas Senate Bill 51, failure to send this form in a timely manner may result in Client being charged for uncollected premium.

Company

Employee First Name

Employee Last Name

Employee Social Security Number

Employee Job Title/Department

Last Date Worked

Date of Last Check

Further Explanation of Termination

If yes, what is the last month of benefits coverage for this employee?

Additional Information File Upload

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Person Submitting Form

Date of Submission

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