Sample Employee Termination Request Form

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(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 Home Address Street / / – – City Rehire Date (if applicable) Marital Status / Single Termination Date Social Security Number / / State Spouse’s Name Spouse’s Date of Birth Married / / / Zip Phone Number (optional) ( ) HOURS OF SERVICE (for Vesting) Enter the following dates..

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