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Employee
Termination Exit Checklist
Employee name:
-------------------------------------------------------- Position:---------------------
Date of hire: ---------------------------------------------- Date of termination:
--------------------
Topics to discuss:
- Salary/Payroll
- Salary through
last day of employment:
- Accrued, unused
vacation through last day:
- Other adjustments
(commission, travel expenses, etc.)
- Disclose any
benefits included as taxable wages
- Total of final
paycheck:
- Employee benefits:
- Health Insurance:
- COBRA information
given to employee
- Date coverage
ends:
- Reimbursement
due employee for premium:
- Insurance company
notified
- Life Insurance:
- Date coverage
ends:
- Insurance company
notified
- 401(k) Plan:
- Withdrawal/Rollover
information given to employee
- Profit Sharing
Plan:
- Employee notified
of any distribution
Return of Company
Property:
____ Identification
badge
____ Keys and key cards
____ Equipment (Laptop PC, pager, cell phone, tools, etc.)
____ Credit cards
____ Books and other printed material
____ Other items, list: ________________________________________________
The terminating
employee's forwarding address:
------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------
Completed by:
------------------------------------------------------------------------------------------------
Name: ------------------------------------------------------------ Position:
---------------------------------
Date: --------------------------
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