Benefits Clearance Form

Clearances are processed during regular business hours. Please allow 48 hours for the process to be completed. Once the employee has been cleared, you will receive a confirmation email. Please submit ONE employee's clearance per form request.

Please review our privacy statement relating to information we collect, choice/opt-out, and correction/updating of personal information before proceeding.

* Name of Separating Employee: (You must type in a response)
 
 
* Separating Employee's "C" Number: (You must type in a response)
 
 
* Separating Employee's Department: (You must type in a response)
 
 
* Date of Separation: (You must type in a response)
  Please enter in this format: MM/DD/YYYY
 
 
* Reason for Separation: (You must select one)
 
Retirement
Termination
Lay Off
Resignation
Death
 
* Name of Employee Initiating Clearance: (You must type in a response)
 
 
* "C" Number of Employee Initiating Clearance: (You must type in a response)
 
 
* Email of Employee Initiating Clearance: (You must type in a response)