Fill and Sign the Fmla Information

{ Insert Date } Insert Name Insert Address Insert City, State, and Zip Code SUBJECT: Short Term Disability Leave (STD) and Family Medical Leave Act (FMLA) Information Dear _______ : This letter is provided to you in response to our notification that you have applied for short-term disability benefits. The Company’s short-term disability (STD) plan is designed to provide you with income and continuation of benefits during periods of disability. According to the STD plan as described in the Employee Benefits Handbook, you may be eligible for full pay or partial pay depending upon your length of service. All days you are away from work due to a disability will be deducted from this period and should be recorded on your timesheet. You will remain on STD until you are released to return to work or until you become disqualified for benefits or if you qualify for long-term disability (LTD). STD may also be designated as a leave of absence under the Family and Medical Leave Act (FMLA). Your STD leave would run concurrently with the 12-week entitlement period provided by FMLA. Enclosed is a FMLA fact sheet explaining eligibility requirements and leave entitlement. Please have your physician complete the attached Certification of Health Care Provider form (Certification). Please review the Certification to ensure it is complete and then return it to me no later than { Insert Date }. This certification is needed for you to qualify for FMLA protected leave. In accordance with FMLA, should you return to work before the culmination of 12 weeks of leave, you will be reinstated to the same or an equivalent position with the same pay, benefits and terms and conditions of employment. However, if your leave of absence requires you to be out greater than 12 cumulative weeks, your position may be filled. Upon returning from a FMLA designated leave, you may be required to provide a fitness for duty certification from your health care provider indicating your fitness for duty. If you are out for more than 30 consecutive days, the Company may require you to submit a re-certification from your health care provider. If you exhaust your STD and remain qualified for unpaid FMLA leave, you may continue your benefits if you make the required employee contribution of the designated amount of coverage at the beginning of each month on unpaid FMLA leave. If your payment is not received on time, your health coverage will lapse, provided the Company gives you written notice at least 15 days before your coverage will lapse. Information about benefits and the Company’s FMLA Policy may be found on the Company Intranet under Employee Information/Company Policies/Employee Policy Handbook. Additional information about STD may be found your Employee Benefits Handbook. Please review the attached documents. If you have any questions or would like to discuss your options, please give me a call at { Insert Phone Number }. Sincerely, ___________________________________________ Manager, Human Resources enclosures: FMLA Certification form FMLA Fact Sheet FMLA Policy