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

Upload File

Person Submitting Form

Date of Submission

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