Sample Separation Agreement Form - Stoel Rives

ADVERTISEMENT
SAMPLE DOCUMENT
[THIS IS FOR INDIVIDUAL TERMINATION OF AN INDIVIDUAL 40 OR OVER
MUST BE REVISED FOR GROUP TERMINATION
INDIVIDUALS 40 OR OVER]
[DATE]
[NAME]
[ADDRESS]
Re: Separation Agreement
Dear [NAME]:
This Agreement, when signed by you, will constitute our entire agreement regarding your
separation from employment with [COMPANY] (“[COMPANY]” or the “Company”). Because
of the subject of this letter, its tone is necessarily formal. However, on behalf of [COMPANY], I
want to express our best wishes for your future endeavors.
As a part of our agreement, we mutually have agreed upon your resignation from
[COMPANY] effective [today,] [DATE]. Your separation will be recorded in our Company
files and communicated by the directors and coaches of [COMPANY] to the other staff and to
the community at large as a resignation. However, [COMPANY] will not contest any claim you
may make for unemployment benefits. You acknowledge that you have received your final pay
today, [including pay for any accrued, unused personal time. ADD IF APPLICABLE.]
Upon separation from your employment today, your existing group health insurance
coverage will continue through [DATE]. After that time, you may choose to continue your
group health coverage under a federal law called COBRA. Under COBRA, you may elect to
purchase continued group health insurance coverage through the Company at the full premium
rate plus an administrative fee for up to an eighteen - (18) - month period. You will receive
additional information about COBRA continuation from Human Resources. [DELETE
COBRA LANGUAGE IF NOT APPLICABLE; ADD STATE EQUIVALENT IF
APPLICABLE; REVIEW POLICY AND CONFIRM WITH INSURER]
This sample document is for example ONLY and is not intended to be used as a template.
© 2010 Stoel Rives
12143511.1 0099865-70012
SAMPLE DOCUMENT
[THIS IS FOR INDIVIDUAL TERMINATION OF AN INDIVIDUAL 40 OR OVER
MUST BE REVISED FOR GROUP TERMINATION
INDIVIDUALS 40 OR OVER]
[DATE]
[NAME]
[ADDRESS]
Re: Separation Agreement
Dear [NAME]:
This Agreement, when signed by you, will constitute our entire agreement regarding your
separation from employment with [COMPANY] (“[COMPANY]” or the “Company”). Because
of the subject of this letter, its tone is necessarily formal. However, on behalf of [COMPANY], I
want to express our best wishes for your future endeavors.
As a part of our agreement, we mutually have agreed upon your resignation from
[COMPANY] effective [today,] [DATE]. Your separation will be recorded in our Company
files and communicated by the directors and coaches of [COMPANY] to the other staff and to
the community at large as a resignation. However, [COMPANY] will not contest any claim you
may make for unemployment benefits. You acknowledge that you have received your final pay
today, [including pay for any accrued, unused personal time. ADD IF APPLICABLE.]
Upon separation from your employment today, your existing group health insurance
coverage will continue through [DATE]. After that time, you may choose to continue your
group health coverage under a federal law called COBRA. Under COBRA, you may elect to
purchase continued group health insurance coverage through the Company at the full premium
rate plus an administrative fee for up to an eighteen - (18) - month period. You will receive
additional information about COBRA continuation from Human Resources. [DELETE
COBRA LANGUAGE IF NOT APPLICABLE; ADD STATE EQUIVALENT IF
APPLICABLE; REVIEW POLICY AND CONFIRM WITH INSURER]
This sample document is for example ONLY and is not intended to be used as a template.
© 2010 Stoel Rives
12143511.1 0099865-70012
SAMPLE DOCUMENT
[NAME]
[DATE]
Page 2
In the future, you should refer all requests for references to [NAME]. He/she will
respond to reference requests by providing your dates of employment and the position held
and will confirm that you resigned your position.
To assist with your transition, [COMPANY] is offering you certain separation benefits in
exchange for your acceptance of the terms of this Agreement and your Release of Claims in favor
of [COMPANY]. Subject to your execution and delivery of this Agreement and expiration of
the revocation period described below, provided you do not revoke, [COMPANY] will pay you
the equivalent of [NUMBER] ([#]) weeks of your regular base pay $[INSERT], less applicable
withholding, and an additional amount of $[INSERT], less applicable withholding, which you
may use to continue your existing health insurance under COBRA or for such other purpose as
you wish (individually or collectively, the “Severance Benefits”). Payment of Severance
Benefits will be made to you as soon as practicable following your execution and delivery of this
Agreement to me, provided you do not revoke.
You acknowledge that [COMPANY] has no legal obligation to provide you with these
additional Severance Benefits except as part of this Agreement. These Severance Benefits are
unique to you and your circumstances and are in lieu of any other separation or severance
benefits to which you might otherwise be entitled under any policy, plan or practice of
[COMPANY].
In consideration for these Severance Benefits and to the fullest extent permitted under
applicable law, you release [COMPANY], its officers, directors, employees, insurers, agents,
representatives and assigns from any claims you might have, whether known or unknown to you
at this time, in connection with your employment or your separation from employment. This
release includes any claims you might have under applicable state, federal or local law dealing
with employment, contract, wage and hour, tort, or civil rights matters including, but not limited
to, applicable state civil rights or wage payment laws, Employee Retirement Income Security Act
(ERISA), Title VII of the Civil Rights Act of 1964, the Post-Civil War Civil Rights Acts (42
U.S.C. §§ 1981-1988), the Civil Rights Act of 1991, the Age Discrimination in Employment Act,
the Older Workers’ Benefit Protection Act, the Rehabilitation Act of 1973, the Americans with
Disabilities Act, the Equal Pay Act, the Family and Medical Leave Act, the Uniformed Services
Employment and Reemployment Rights Act, the Fair Labor Standards Act, sections 503 and 504
of the Vocational Rehabilitation Act, the Rehabilitation Act of 1973, the Worker Adjustment and
Retraining Notification Act, Executive Order 11246, Oregon Revised Statutes chapters 652-654
and 659, all as amended, and any regulations under such laws.
© 2010 Stoel Rives
12143511.1 0099865-70012
SAMPLE DOCUMENT
[NAME]
[DATE]
Page 3
This release, however, does not affect any rights you might have for benefits under any
applicable medical insurance, disability, workers’ compensation, unemployment compensation or
retirement program.
You agree to hold confidential the terms of this Agreement, except to the extent that
disclosure of its terms to your accountant, attorney and taxing authorities may be necessary for
your financial or legal affairs or as may be required by law. [You acknowledge that the
obligations under the Confidentiality Statement you signed on [DATE] will continue
following the termination of your employment and this Agreement.]
You agree not to intentionally disparage or make false, adverse or derogatory remarks
about the Company, its affiliated companies and all of each entity’s officers, directors,
employees, insurers, agents, representatives and assigns.
You agree to return all Company property in your possession including, but not limited
to, office and building keys, card keys, Company-issued credit or calling cards, computer or
computer equipment, cell phone, fax machine, e-mail and voice mail passwords, Company
documents, account files, customer and product lists and information, equipment, supplies and
any other property belonging to the Company.
You acknowledge that: (a) you have been advised in writing to consult with an attorney
prior to executing this Agreement; (b) you have read the release and understand the effect of your
release and that you are releasing legal rights; (c) you are aware of certain rights to which you
may be entitled under certain statutes and laws identified in the release; (d) you have had
adequate time to consider this Agreement; and (e) as consideration for executing this Agreement,
you have received additional benefits and compensation of value to which you would not
otherwise be entitled.
You acknowledge that this Agreement contains the entire agreement between you and
[COMPANY] regarding the terms of your separation from employment. You further
acknowledge that you have been given 21 days to consider this Agreement and discuss it with
financial or legal counsel of your choice; and that you voluntarily sign it and agree to be bound
by its terms. You understand that this Agreement must be signed within 21 days after [DATE]
for you to be entitled to the Severance Benefits given under it. However, you may revoke this
Agreement by sending a written statement to that effect addressed to the attention of [NAME],
[COMPANY], [ADDRESS], within 7 days after you have signed it. Unless you revoke it, the
Agreement will be effective on the 8th day after you have signed it and
will then
[COMPANY]
provide you with the Severance Benefits stated in this Agreement.
© 2010 Stoel Rives
12143511.1 0099865-70012
SAMPLE DOCUMENT
[NAME]
[DATE]
Page 4
If you wish to enter into this Agreement, please sign the enclosed copy where indicated
and return the signed Agreement to [NAME] using the enclosed, stamped, self-addressed
envelope no later than [DATE].
Sincerely,
[NAME]
[TITLE]
I voluntarily agree to and accept the terms of this Agreement.
_______________________________
______________________________
[NAME]
Date Signed
© 2010 Stoel Rives
12143511.1 0099865-70012

Download Sample Separation Agreement Form - Stoel Rives

452 times
Rate
4.3(4.3 / 5) 32 votes
ADVERTISEMENT
Page of 4