Health Net 2011 Annual Report Download - page 246

EXHIBIT A
WAIVER AND RELEASE OF CLAIMS
This WAIVER AND RELEASE OF CLAIMS (this “Release” or “Agreement”) is made and entered into by and between Health
Net, Inc. and its affiliates and subsidiaries (hereinafter referred to as the “Company”) and (hereinafter referred to as the
“Employee”).
WHEREAS, the Company and Employee are entering into this Release as a condition to Employee’s receipt of severance pay
upon his or her termination of employment with the Company.
NOW, THEREFORE, the Company and Employee agree as follows:
In the event that the Company rehires Employee and the number of months between Employee’s Termination Date and the
date of his or her re-hire, if any, is less than the number of months of Employee’s monthly base salary was taken into
account to calculate his or her lump sum severance payment, then the Employee shall repay to the Company an amount
equal to the amount of his or her severance payment multiplied by a fraction, the numerator of which is the number of
months set forth above on which the severance payment was based, minus the number of months (any partial month will be
prorated) during which the Employee was unemployed, and the denominator of which is the number of months on which
the severance payment was based (e.g. if an employee receives three months of severance pay and is re-hired by the
Company two months after his or her
A-1
1. Employee’s employment with the Company shall terminate on (the “Termination Date”). Following termination of
employment, Employee shall not represent to anyone that he or she is an employee of the Company and shall not say or do
anything purporting to bind the Company. For purposes of this Release, Employee will terminate employment only if such
termination constitutes a “separation from service,” as defined in Treasury Regulation Section 1.409A-1(h), and the
“Termination Date” shall mean the date of Em
p
lo
y
ee’s “se
p
aration from service.”
2. Upon Employee’s acceptance of the terms set forth herein as evidenced by Employee’s signature below and upon expiration of
any revocation period, the Company shall provide Employee with the following benefits and payments, subject to the terms and
conditions set forth in this Release:
a. Employee shall be entitled to receive a lump sum severance payment under the terms of Employee’s employment
agreement or an applicable Company severance policy (as in effect from time to time) in the amount of $ (which is
equal to months of Employee’s monthly base salary in effect as of the Termination Date), subject to withholding
for payroll taxes and applicable deductions. The severance payment shall be made on the payday for the payroll period
beginning after the effective date of this Release, and in no event later than March 15 following the calendar year in which
the Termination Date occurs.