Board and Governance
Part 1: Introduction to MEBP
Part 2: The New Employee
Part 3: Contributions, Insurance Coverage and Remittance
Part 4: The Existing Member
Part 5: The Exiting Employee
Part 6: Additional Employer Information
Part 7: Annual Yearend
Active Member FAQ
Retired Member FAQ
©2021 Municipal Employees Benefits Program
Separation Notice (Form #10.W)
Date of Birth
Type Of Separation
Executor Contact Information
Date of Separation (YYYY-MM-DD)
Was this employee on a leave of absence or lay off prior to the date of separation?
Last Day Worked (YYYY-MM-DD)
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?
Hourly Rate of Pay
or Annual Salary
How many pay periods are there in the year of separation?
1st Pay Period Start Date (YYYY-MM-DD)
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)
A) Current Year Total Pensionable Hours Worked
B) Current Year Base Hours
C) Current Year Pensionable Service = A/B
If employee was Full time, were there any unpaid LOA/non-pensionable hours in the year of separation?
If yes, how many hours?
Pensionable Earnings and Contributions paid in the current calendar year (separation year)
Current Year Pensionable Earning
Required Employee Pension Contributions
Year's Retro Pay Was Paid For
Retro Pensionable Earnings
Retro Required Employee Pension Contributions
Total Pensionable Earnings
Total Required Employee Pension Contributions
Name of Contact Person
Submit Completed Form