Fill and Sign the Leave of Absence Letter Form

Leave of Absence Approval Form Employee Name (print):                                                 SS#                         Location                                     Current Position: ___________________________ I hereby request a Leave based on the following : (check one) Medical Personal Funeral Military Family If "Personal" please provide a brief statement as to the nature of the leave. ________________________________________________________________________ ________________________________________________________________________ My leave will begin on:                         I will return to work on:                         I understand that under the Family and Medical Leave Act (“FMLA”), employees are allowed the opportunity to take leave under certain defined circumstances. I acknowledge that the Company has provided a notice of my rights under the FMLA. I understand that I am to comply with the provisions of the leave policy, including completion of this form. I also understand that leaves of absence are to be approved by management for periods exceeding three working days and not exceeding 12 weeks per 12-month period, unless state law provides for a greater period of leave, in which case those limits apply. I understand compensation and performance reviews are postponed by the overall time of my leave of absence. I understand that upon my return to work on the date indicated, the company will reinstate me to my former position or an equivalent one, in accordance with applicable law and company policy. However, I have no greater right to reinstatement than if I had been continuously employed during the FMLA leave period. I understand that certain changes in hours or schedules may occur due to business necessity. If I fail to return to work on the return date (unless further approval is obtained), I will be considered as having voluntarily resigned effective on my last day of work prior to my leave. Any accrued paid leave must be applied to this leave before any unpaid leave time. I understand that a medical leave is the period of time my physician says I cannot work until the time the physician says I can return to work. For leave based on personal illness, a physician's release showing I am able to resume my normal job, or any restrictions, must be provided to my supervisor before I may return to work. Failure to provide the physician's statement may lead to the denial of a leave, denial of the continuation of leave, or denial of reinstatement. My medical leave will end if my physician releases me to return to work, either on a part-time basis or with certain restrictions, and the company agrees to accommodate my physician's instructions by temporarily modifying my job. If I do not accept the modified position, I must either apply for a personal leave or terminate my employment. All requests for personal medical and family leave due to the serious illness of a family member must include a physician's statement. I acknowledge that it is my responsibility to remain in contact with my supervisor during my leave, and I agree to contact my supervisor at least once a month regarding my status and my intent to return to work. During my leave, I may be contacted at the following address and phone number: Address:                                                                                                             Telephone Number                                                 I understand I may not work while on leave, except as part of an approved rehabilitation program and that I am to comply with applicable company policies, such as confidentiality and conflict of interests. I understand failure to comply with applicable policies may lead to discipline. HEALTH COVERAGE I DO I DO NOT (check one) wish to continue my current group health insurance coverage (if neither is circled, health coverage will continue as long as premiums are timely paid). I understand that contributions are due in full on the first day of each month and that failure to pay my monthly contributions may result in the termination of coverage for me and my dependents. I also acknowledge that it is my responsibility to notify the benefits department in writing of any changes in my coverage in accordance with the procedures outlined in my benefit handbook. I understand no benefits accrue during my leave. Nothing herein creates a contract between the company and any person for employment or entitlement to benefits. No commitments regarding employment or continuation of benefit programs are made herein. Employee's Signature: _______________________________________________ Date: ____________ Approval: Management Representative (Printed):                                                                   Management Representative (Signature): ____________________________________________