Separation Notice (Form #10.W)

Employee Information

Last Name First Name Date of Birth Address City Province Postal Code

Separation Information

Type Of Separation Termination/Resignation Retirement Death

Executor Contact Information Last Name First Name Address City Phone Number Postal Code

Date of Separation (YYYY-MM-DD)

Was this employee on a leave of absence or lay off prior to the date of separation? Yes No

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? Yes No Not Applicable

Did this employee contribute to the Disability Income Plan? Yes No Not Applicable

Payroll Information

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? Yes No

How much?

Was the vacation pay pensionable? Yes No

Were the vacation hours pensionable? Yes No

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? Yes No

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

Employer Information

Employer Number Employer Name Name of Contact Person Email Phone