Sfn 19451 - Employee Exit Checklist (State Of North Dakota) printable pdf download

EMPLOYEE EXIT CHECKLIST

STATE OF NORTH DAKOTA

SFN 19451 (5-07)

Employee Name

Termination Date

Instructions: This exit checklist is intended to act as a guide for the appointing authority and employee when an

employee’s service with an agency is ending. After a particular section has been completed, the person who

completed the section should initial and date the form. When the entire checklist is completed, the form may be

placed in the employee’s personnel file.

Initials

Date

Employee Responsibility

Submit letter of resignation and include date of planned termination and future mailing address.

Organize records and files (hard copy and computer) at workstation.

Agency Responsibility

Agency must submit proper forms to PERS as applicable. The following forms can be found in the Retirement Kit on

PERS website at [Note: The Suppress DDP Advice Print will be turned off, so the employee can

receive a hard copy of their advice.]

Notice of Status or Employment Change, SFN 53611

NDPERS Request for Benefit Information, SFN 53603

Application for Retirement Benefits, SFN 2562

Conversion of Unused Sick Leave Application – Defined Benefit, SFN 58358

Application for the Partial Lump Sum Option – Defined Benefit, SFN 54373

Legible photocopies of birth certificate, spouse’s birth certificate & marriage certificate

Designation of Beneficiary for the Group Retirement Plan, SFN 2560

Authorization for Direct Deposit for Annuity Payment, SFN 18379

Form W-4P (Substitute) Tax Withholding Certificate,, SFN 51506

Continuation of Group Health Insurance Coverage (COBRA), SFN 53799

Retiree Group Health Insurance Application, SFN 16277

Retiree Life Insurance Application, SFN 53622

Prudential Conversion Information Request Form

Retiree Continuation of Group Dental Coverage (COBRA), SFN 53800

Retiree Dental Insurance Enrollment/Change, SFN 53504

Retiree Continuation of Group Vision Insurance Coverage (COBRA), SFN 53801

Retiree Vision Insurance Enrollment/Change, SFN 53505

Authorization for Automatic Premium Deduction, SFN 50134

UNUM Election for Portable Coverage

Continuation of Coverage in Medical Spending Account (COBRA), SFN 53512

Annual leave/sick leave payout.

Complete Personnel Action Form (PAF)/SFN 13090, which lists action taken, last date of

employment, and reason for separation.

Notify computer support staff when to terminate ndgov account, PeopleSoft and other system IDs,

and email; remove or change public drive and clean hard drive if necessary.

Obtain access card/keys, ID, business cards, credit cards, phone card, uniforms, laptop computer,

cell phone, and other state property in employee’s possession.

Ask employee to update supervisor on status of projects/tasks.

Complete inventory check of employee’s workstation. Determine if computer access codes or

passwords need to be changed.

Complete termination questionnaire. (optional)

Organize employee’s personnel file and retain for six years after last action.

Sfn 19451 - Employee Exit Checklist (State Of North Dakota)

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