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Personal Information
SSN: First Name: Last Name: M.I:
Street Address: City: State: Zip:
Date of Hire: Location Code: Lookup Employee ID #: DOB:

Supervisor Information
Name: Phone: Email:

Request for Leave of Absence
Home Phone: Cell Phone:
Preferred Number for communications:      
Work Email: Confirm Email:
Personal Email: Confirm Email:
We would prefer to communicate with you via email including our compliance correspondence.
Do you agree to receive all correspondence via email?

  
What email address would you prefer we send your correspondence to?            
Email Address: Confirm Email:

Leave of Absence Information
Last Day Worked: Dates of Leave: From      To
Is this leave related to your own pregnancy?        
Reason for Leave Request:
If you have selected to take leave because of someone other than yourself please specify your family relationship:
Please provide an explanation of your need for a Leave of Absence.
If you selected "My Own Serious Health Condition" is this health condition work related?      
If work related can you please give us an explanation:
If requesting a school activity leave, please explain:
Will you file for Short Term Disability?      
Is this periodic, intermittent or reduced schedule leave?      
If "yes" please explain:
If you wish to use your accrued or unused paid time off (PTO), please contact your office manager.

Note: PTO hours are coordinated with Short Term Disability, Long Term Disability, and/or State Disability. Maximum coordinated hours per pay period is 86.67hrs for semi-monthly pay cycle. You may be required to use your PTO depending on the leave taken.

 

Please acknowledge the following statements:
I understand that if I do not return to work on the expected date of return without contacting the Leave Center, my supervisor, or Human Resources in advance, my employment may be ended voluntarily due to job abandonment.
I understand that my leave of absence is unpaid unless I am required to use or request payment of accrued, unused PTO or I qualify for Short Term Disability, Long Term Disability, or state disability if applicable.
I understand that I am required to provide a physician certification for a leave related to a serious health condition within 15 days of the first day of my absence and recertification every 30 days thereafter or as reasonably requested by the Company.
I understand that taking a leave may impact certain of my benefits. The Company will continue to pay the Company share (but not my share) of my health insurance benefits for any portion of my leave designated as FMLA or as leave provided under another State leave law. If I am not able to return to work following FMLA or other state eligible leave, my benefits will be canceled and I will be offered COBRA coverage.
I understand that I must provide a physician certification prior to my return to work date that provides a full release or identifies specific limitations/restrictions on my ability to perform the essential functions of my job. The return to work release must be dated within 3 days of the date I will return to work. Upon return to work, my office manager must notify the Corporate office of my return.
I understand that to qualify for FMLA, I must work in an office in which 50 or more employees are employed by the company or work within 75 miles of the office location, worked for at least twelve months and 1,250 hours in the twelve months immediately preceding the leave. (All office locations qualify.)

I understand that upon return of FMLA leave, I will be reinstated to the same or equivalent position with the same pay, benefits, and terms and conditions of employment provided that no employee has greater rights to reinstatement or other benefits and conditions of employment than if the employee had been continually employed during the same FMLA period.

I understand that I am not being asked to provide any genetic information in response to any request for medical information, including my family medical history, the results of my or my family member’s genetic tests, the fact that I or a family member sought or received genetic services, and genetic information of a fetus carried by me or my family member or an embryo lawfully held by me or a family member receiving assistive reproductive services.

I understand that the Company may require up to two additional medical opinions regarding any health certifications I provide. Such opinions, if requested, will be at the Company's expense.
I certify the foregoing information is true and correct and acknowledge it is my responsibility to notify the Leave Center of any leave of absence changes as soon as I am aware of them.