Separation Notice (Form #10.W)

Employee Information

Separation Information

Type Of Separation
Executor Contact Information
Was this employee on a leave of absence or lay off prior to the date of separation?

Basic Life Insurance & Disability Income Plan

Did this employee contribute to Basic Life Insurance to the Date of Separation?
Did this employee contribute to the Disability Income Plan?

Payroll Information

During the year, did the employee receive any vacation pay?
Was the vacation pay pensionable?
Were the vacation hours pensionable?

Pensionable Service for the current calendar year (separation year)

Pensionable Earnings and Contributions paid in the current calendar year (separation year)


Employer Information

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