Having been found fit in accordance with the Public Service Long Term Disability Income Continuance Plan Regulation for:
Gainful EmploymentORReturn to own or similar duties
(approved for LTDI benefits for 24 months or longer)
I did not return to activeemployment within the three (3) month period from the determination date.
My employment with the Government of Alberta is therefore terminated effective <Employer to enter termination date> and I confirm upon signing this document, that I was not employed with another employer at the 60% gainful level or more during the three (3) month period from the determination date.
By signing this Severance Agreement, I acknowledge that the Employer will not be pursuing accommodation.I also herewith release the Government of Alberta, its officers and employees from any and all claims which I may now or in the future have arising out of my employment with the Government of Alberta or the termination of such employment.
If during the period <enter date> to<enter date>, the “Employer” as defined in the Public Service Act or a “Provincial Agency” as defined in the Financial Administration Act:
a)employs myself on a full-time or part-time basis, or
b)retains myself, either directly or indirectly, on a fee-for-service basis the amount paid to myself directly or indirectly by the Employer or Provincial Agency during the period shown above, less any withholdings required by law made at source, shall be paid by myself to the applicable Long Term Disability Plan Fund (Management, Opted Out and Excluded or Bargaining) following completion of the above period.My obligation for repayment to the Long Term Disability Plan Fund, less any withholdings required by law, shall not be for an amount greater than the amount Iwas paid by the Fund.
Signed and witnessed in / , in the Province of
City/Town
, this / day of / , / .
Employee: / Witness:
Please print name / Please print name
Signature / Signature
Severance Payment Schedule
Full years of
Continuous Employment / = / Weeks of Pay at
Regular Rate of Pay
1 / 14
2 / 15
3 / 16
4 / 17
5 / 19
6 / 22
7 / 25
8 / 28
9 / 31
10 / 34
11 / 37
12 / 40
13 + / 43
Bi-WeeklyRate of pay* on date of termination for severance calculation:
*Present day classification (or its equivalency) salary rate. / $
Date continuous employment commenced:
Number of full years of service for severance calculation:
Date LTDI benefits ceased:
Date of termination of employment:
Date of termination of health benefits, dental and life insurance coverage:
Calculation of severance:
weeks x / $ / per week = $ / Severance Payment / .
Employee Signature / LTDI Liaison Officer
Date / Date
cc:Payroll File
CHR LTDI Unit
LTD 37 [2013/04]1