Employee Death and Final Pay in the Same Tax Year Letter


To: The Family/Estate of


Fiscal Assistant, Business Office

XXXXXXXX Public Schools


City, State, Zip

Re: Employee Name

Employee Address

Please accept our deepest sympathy from all of us in the Business Office. You and your family are in our thoughts and prayers during this difficult time. Please call us or come in if we can help you in any way.

XXXXXXXXXXX was a wonderful person and will be missed by all of us. My hope is that XX realized how many co-workers, students and parents appreciated XXXX as well.

Final Pay

XXXXX’s final pay will be paid in a warrant made payable to the Estate of XXXXXX on XXXXX. Federal income tax and unemployment are not permitted to be withheld on this payment. Social Security and Medicare taxes are withheld on XXX wages per IRS code. Retirement will be withheld on XXX wages. The warrant will be made payable to the Estate of XXXXXXXXXX.

Details: Gross XXXX wages $$$$$$

Sick leave cash out $$$$$$

Vacation cash out $$$$$$$

Gross Amount $$$$$$$

Net Amount $$$$$$$ (after deductions)

Sick Leave and Vacation Leave

The final pay on XXXXX will include XXXX sick leave cash out and vacation cash out. By state law (WSC 41.04.340), the sick leave cash out is paid at 25% (1 day for 4 days). XXXX sick leave balance was XXXX hours. XXX’s vacation balance was XXX hours and is cashed out at 100%.

W-2 Form

In January a W-2 form will be issued showing taxable wages and federal withholding to the date of death. Social Security and Medicare wages will show total amount earned and paid, including final pay.

1099 Form

In January a 1099 Misc. form will also be issued showing the taxable payment made after the date of death.

July Insurance Benefits

Health Insurance for XXXXXXXXXXXX (Copies of insurance information is enclosed).

Future Medical Insurance and COBRA: XXXXXXX’s coverage under the XXXXX Public Schools health insurance group plan with XXXXXXXXXX will end on XXXXX. They will be eligible for 36 month of COBRA insurance with WEA (Washington Education Association) paying for the first 12 months of health insurance for XXXXXXXXX providing you complete the COBRA paperwork timely. XXXXXXXXX will receive notification and an application at the above address from Rehn & Associates in Spokane in care of XXXXXX A.W. Rehn & Associates handles the COBRA insurance for XXXXXX Public Schools. They may be reached at P. O. Box 5433, Spokane, WA 99205-5433. If you wish to contact them by phone, there number is 1-800-872-8979. Ask for the Cobra Department, Non-Union section.

Please write on the top of the application for XXXXXXXXX “Surviving Dependents”

Vision Insurance and COBRA:

XXXXXXXXX’s coverage under the XXXXXX Public Schools vision group plan with Vision Service Plan (VSP) paid thru Premera Blue Cross will end on XXXXXXX. COBRA insurance is available for up to 36 months. This amount is not paid for by WEA for any length of time. At the current time the cost is $XXXXXX (plus an approximate 2% COBRA administrator fee) per month. You will receive notification from A.W. Rehn & Associates in Spokane.

Dental Insurance and COBRA:

XXXXXXXX coverage under the XXXXXX Public Schools dental group plan with XXXXXXXXX will end on July XXXXX. COBRA insurance is available for up to 36 months. This amount is not paid for by WEA for any length of time. At the current time, the cost is XXXXX (plus an approximate 2% COBRA administrator fee) per month. You will receive notification from A.W. Rehn & Associates in Spokane.

Provident Life & Accident Insurance (Automatically provided with Premera Blue Cross medical coverage)

Policy Number: XXXXX

Beneficiary: The latest document we have on file shows XXXXXXX but Unum Insurance will need to verify.

Benefit Amount: See enclosed Premera Blue Cross Plan 2 book, page 66

Contact Person: Jennifer Weddle with Aon Hewitt Consulting at (206) 467-4647 or Lisa Paqain at (206) 467-4632. She is sending the paperwork to XXXXX in the Business Office at XXXXXX Public Schools. Once the form is completed by the family/estate and XXXXXX Public Schools, it will be sent to LouAnn McCarthy at Unum Insurance Company. If you have questions regarding the completion of the paperwork, please contact LouAnn at 1-800-445-0402.

Attachment to follow when received: The insurance forms from Unum will be forwarded to you as soon as they are received. Please complete the beneficiary statement section, attach a death certificate and return to XXXXXX at XXXXXX Public Schools Business Office.


Retirement Name: Washington State Department of Retirement Systems (DRS)

Plan Number: SERS Plan 3 (School Employee Retirement System)

Contact Phone Number: 1-800-547-6657

Beneficiary: Please check with the Department of Retirement Systems regarding the beneficiary. DRS has the original of this form.

XXXXX Public Schools will report the last day worked to The Department of

Retirement Systems (DRS). The Department of Retirement Systems will receive this in our monthly transmittal approximately XXXXXXX. DRS has asked that the family/executive contact them at their toll-free number above; they cannot accept official notification from the employer. After dialing the toll-free number, select option #0 and ask for a SERS 3 Death of an Active Member representative. Upon notification, they will provide you a packet with benefit information. Please see the following paragraph about XXXXX’s ICMA account which is the defined contribution section of his retirement.

ICMA is the company the Department of Retirement Systems has hired to invest and manage the paperwork regarding the employee’s contributions for Plan 3 retirement funds. Please be sure to ask the contact person at the Department of Retirement Systems if the packet will include information from ICMA also. If not, please have them provide you with a contact person and phone number.


PSE (Public School Employees) – XXXXX is the union XXXXX belonged to. I spoke with Elyse Maffeo at 206-794-6017. She stated that the union does not carry life insurance on their members. She said members do have access to purchase XXXXX insurance. If XXXXX did this, he would be making payments.

Again, please contact us if you have any questions or we can be of any assistance.

We are so sorry for your loss.




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