Pregnancy Disability Leave Request Form

Pregnancy Disability Leave Request Form

Employee Name: Preferred Phone:

First 5-digits SSN#: Regular work hours per week: 40 31-34 20-30 Other

Days per wk scheduled to work: M T W TH FRI SAT SUN Local HR Rep:

In order to request a medical leave of absence, thoroughly complete each section below and follow the How to Apply for a Leave of Absence. This form must be returned to your manager, 30 days prior to your first day of absence, or within 2 days of absence due to unforeseen circumstances.

PREGNANCY DISABILITY LEAVE

The Pregnancy Disability Leave of Absence policy allows an employee to be away from work, in full workweek increments, on a reduced work schedule, or intermittently. This leave will run concurrent with any applicable federal and/or state leave laws.

Employees may request to take a pregnancy disability leave of absence for any periods of actual disability caused by pregnancy, childbirth or related medical condition, including time off needed for prenatal care, severe morning sickness, doctor-ordered bed rest, and recovery from childbirth. Medical certification from the employee’s health care provider will be required. A pregnancy disability leave of absence may be approved for absences in 15 minute increments, up to 16 workweeks with medical certification.

HOW TO APPLY FOR A LEAVE OF ABSENCE

1. Read the Pregnancy Disability Leave policy located on sharepoint->Human Resources->Policies and Procedures;

2. Complete this form in its entirety;

3. Obtain you Manager’s signature;

4. Fax completed form to Corporate Benefits confidential fax at (858) 882-9060 and;

5. Call CIGNA LOA Solutions at 800-558-9451

Please note that you have not been approved for a leave of absence until you have received a written notice of approval from CIGNA LOA Solutions or Corporate Benefits. Unauthorized absences may result in disciplinary actions, up to and including termination of employment.

ANSWER ALL QUESTIONS BELOW

A. Yes No
Are you requesting leave due to your own disability caused by pregnancy, childbirth or related medical condition, including time off needed for prenatal care, severe morning sickness, doctor-ordered bed rest, and recovery from childbirth? If you answer “no” then you are not eligible for a Pregnancy Leave. Do not complete this form.

B. Yes No
Are you requesting intermittent leave or a reduced leave schedule due to medical necessity? If “yes” provide the details of your proposed new work schedule. (i.e. M-F 8-12 for three weeks):

C. Yes No Not Applicable
Are you requesting to utilize unused available Sick Leave? If “yes” how many hours? . SL will then be paid in accordance with the Sick Leave Policy.

Page 2

D. Yes No Not Applicable
Are you requesting to utilize unused accrued Vacation hours if you exhaust available SL? If “yes” how many hours? . Vacation Time will then be paid in accordance with the Vacation Time Policy.

E. Yes No
Will you be applying for Family Leave to baby bond, once you have delivered and are no longer deemed as disabled? If “yes” you must request your Family Leave 30 days prior to the end of your disability date. Read the Family Leave of Absence policy.

DATES OF PREGNANCY LEAVE REQUESTED

I request leave to begin on (1st work day of absence)

I will return to work on (1st returning work day)

EMPLOYEE STATEMENT:

I certify that I have read and understand the Cricket Communications pregnancy disability leave of absence policy available to me via the Share Point intranet. I understand the instructions on this form and will comply with the leave of absence policy. I also understand that I am responsible to pay my portion of health benefits while on a leave of absence.

Print Name:

Manager’s instructions

Once you have received both pages of this completed request form, sign below to knowledge receipt, then return this signed form to the employee. Your Human Resources rep or Benefits Manager will notify you and the employee of the approval status.

Print Name:

HRMS/Payroll Use Only