Family or Medical Leave Request Form

Family Medical Leave Request Form

To submit a new leave request, please complete and fax or email this form to 469-535-2415 or FML_Leave_Team@glic.com.

The employee and employer sections can be completed separately, but need to be submitted together.

Employee Section

1. Employee Name:

2. Employer Name:

3. Employer Group ID Number:

4. Employee Home Mailing Address: City: State: ZIP:

5. Employee Telephone Number:

Employee Work Email Address:

Employee Personal Email Address:

8. Date of Birth:

9. Social Security Number:

10. Gender: Male Female

11. Preference for Receiving FML Documents: Mail Personal Email Work Email All

13. Is Disability Due to Your Employment? Yes No

If yes, have you filed a Workers’ Compensation claim? Yes No

Is disability due to an accident? Yes No

15. Is Surgery Scheduled? Yes No N/A Surgery Date:

16. Brief Description of Illness, Injury or Condition:

17. Are you eligible to receive any other income? Yes No

18. Please Indicate Type of Leave Reason: Employee Health Condition Family Health Condition Pregnancy/Maternity Care for Newborn (Baby Bonding) Adoption Foster Care Family Injured Service Member Family Injured Veteran Family Military Exigency Other

18. Estimated Delivery Date / Delivery Date:

19. Date of Birth:

20. Child’s Gender: Male Female

21. Child’s Delivery Type: Vaginal C-Section

22. Pregnancy Complications Description - If Applicable:

23. If Your Request Is For Employee Health Or Pregnancy:

24. Family Member’s Name:

25. Family Member’s Date of Birth:

26. Family Member Gender: Male Female

27. Relationship to Employee: Child Parent Spouse Domestic Partner Sibling Aunt Uncle Cousin Fiance Grandparent Grandchild Nephew Niece Other

28. Relationship Attribute: Biological Step In-Law Other

Physician Information

Printed Name of Physician: Specialty:

Printed Address of Physician: Telephone Number:

Fax Number: Email Address:

29. Last Day Worked:

30. Leave Start Date:

31. Anticipated End Date:

32. Leave Type: Continuous Leave Intermittent Leave Reduced Schedule Leave

33. Return to Work Date: Actual Estimated

34. If Reduced Schedule Leave - Hours Missed/Week: Hours Missed/Day: Anticipated Weeks of Leave:

Employer Section

1. Employer Name: 2. Plan Number:

3. Employer Address: City: State: ZIP:

4. If Branch or Affiliate, Please Provide Name of Parent Company:

5. Date Employee Terminated/Resigned:

6. Employee Name:

7. Employee Social Security Number:

8. Employee Date of Birth:

9. Employee Job Title:

10. Date of Employment:

11. Is Employee Temp or Rehire? Temp Rehire

12. Rehire Date:

13. Adjusted Service Date:

14. Normal Work Schedule: Mon Tues Wed Thurs Fri Sat Sun Hours/Week: Hours/Day:

15. Actual Last Day Worked:

16. Hours Worked on Last Day:

17. Employee’s Work State:

18. Does Employee’s Work Location Meet the FMLA 50/75 Rule? Yes No

19. Hours Worked in Past 12 Months:

20. Employee’s HR Contact Name: Email: Phone Number:

21. Employee’s Supervisor Name: Email: Phone Number:

22A. Did This Event Arise Out of Employment? Yes No

22B. Has a Workers’ Compensation Claim Been Filed? Yes No

23. Did the Employee Elect STD Coverage? Yes No N/A Effective Date:

24. Employee Insurance Class:

25. Date Employee Returned to Work: Part Time Full Time

26. Vocational Assistance Contact Person: Phone:

27. Salary Information: Hourly Weekly Bi-Weekly Semi-Monthly Monthly Yearly

Employee’s Base Salary: Employee’s Total Bonus and Commissions Over Last 24 Months:

Effective Date of Employee’s Last Salary Change:

Year-to-Date Salary:

28. If “Yes,” please complete the following: Paid by Employee Pre Tax Post Tax

29. Job Description - Please fully complete the below details about the physical aspects of the employee’s job during a normal shift.

Printed Name of Authorized Person: Title:

Telephone Number: Ext: Fax Number: Email Address:

Authorization to Obtain Information

Medical records and other information

Send to: Group STD Claims, P.O. Box 14331, Lexington, KY 40512

Customer Service: (800) 268-2525 FAX: (610) 807-8270

Documents can be returned electronically at www.GuardianAnytime.com. Click on “Secure Channel” on the Guardian Anytime home page.

I, the undersigned, authorize any physician, medical or mental health professional, medical practitioner, hospital, clinic, healthcare provider, pharmacy, therapist, insurer, employer, financial institution, governmental agency, or other organization or person with knowledge of the insured or the insured’s health to give Guardian information in its possession about the insured.

I understand this authorization may affect the handling of the claim if revoked or altered. I understand I may revoke this authorization in writing at any time.

Name of Insured:

Address:

Claim #: Policy #: Date of Birth:

Fraud Warning Statements

The laws of several states require the following statements to appear on the authorization form:

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

California: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.