Shaffer Insurance Services, Inc.- Benefits Division

NOTIFICATION OF TERMINATIONS

 

 

Employer:                                                                                 Date:

 


Prepared By                                                                    Phone: 

 

 

 


Employee & Social Security number

 

Termination Date

 

List all Benefits that you are Terminating

Type of Benefits:

(Group Health; FSA Medical (reimb).,and/or Ind. Prem. (reimb.)

 

LAST PAYPERIOD WITHHELD

Did you take a deduction on that day

 

YTD Total Deposits Withheld

 (PLEASE PROVIDE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comments:

 

 

 

 

 


Please notify us immediately if the terminated employee participated in a benefit for which reimbursement

checks are issued; a delay in our notification could cause a negative balance in the employee’s account. 

 

Please call our office should you have any questions concerning this form or your account.

 

 

Regarding Terminated Employees and Invoicing

 

 

If an employee is active at any time during the month, the employer will be billed for that employee for that month.  If an employee terminates or quits and we are not notified until the following month, you will be billed for that employee for the following month also. 

 

 

Example:

 

Jack, the employee, works for “Your Company”, participates in the Flexible Spending Unreimbursed Medical benefit and is terminated September 23rd.  “Your Company” notifies Shaffer Ins. Services Inc. – Benefits Div.  of his termination on October 2nd.  Jack submits several receipts in October and, having the funds in his account, he is issued a reimbursement check.  When “Your Company” receives their invoice for September, Jack is listed as an employee and you are charged for him.  October invoice is received and still, Jack is listed.  “You’re Company”, thinking that we failed to terminate Jack, crosses him off the October invoice, indicates that Jack was terminated last month and deducts Jack’s charge from the amount billed. Our system will bill for an employee even if that employee was active one day of the month.  Because of the notification being in October, the system will charge for the terminated employee in October.  If the notification was missed until November, the employee is charged for November also. 

 

If the employee participated in a reimbursement benefit (Medical, Dependent or Individual Insurance policy) and we continue to issue reimbursements after the termination date, it is possible that the employee will be included on the invoice until their account has a zero balance, or the 90 day grace period has passed.

 

Your business is very important to us and we want you to know that we are committed to providing you with “more than expected” service.  We want the opportunity to resolve any problems or concerns that you may have regarding your account to your satisfaction. If you have any questions, please feel free to call us.

 

Thank you,

 

Shaffer Insurance Services – Benefits Division

(661) 575-9331 - Office

(661) 280-2016 - FAX

(866) 412-5872 – Toll Free