TO: [Name of Terminated Employee]
SUBJECT: Separation Arrangements

In connection with your separation, your attention is called to the following matters:

1. Your coverage under _______________ will be continued for [specify] days from date of termination. Under federal law (COBRA), you may be covered under this policy for up to 18 months by paying the Company the premium amount specified below within 30 days of termination and by subsequently continuing to pay the premium in a timely fashion. Failure to pay the premium within any 30–day period will result in discontinuance of the insurance.

Your GROUP PREMIUM RATE is: _______

Your HEALTH PLAN NUMBER is: _______

Use this number in all correspondence concerning your benefits.

2. Your GROUP LIFE INSURANCE policy terminates on the last day of your employment, but it can be converted without a physical examination and at a higher individual rate within 30 days of termination. If you wish to convert, contact the [specify insurance company] within the next 30 days.

3. Your WEEKLY SICKNESS and ACCIDENT DISABILITY INSURANCE terminates on the last day of employment and is not convertible to an individual policy.

4. (if applicable.) When the next PROFIT SHARING DIVIDEND is determined, a check for your proportionate share of the dividend will be mailed to you within 60 days thereafter.

OR

5. (if applicable.) Since you have not satisfied the vesting requirements under our PENSION PLAN, you do not have any vested rights in the plan.

If you have any questions about these matters, please call.

________________

Personnel Director