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Family and Medical Leave Act (FMLA) Leave Application for Continuation of Group Benefits

 

Before completing, please read document titled
"Information on Continuation of Benefits
While on Family and Medical Leave"
and FMLA Rates

 

Employee's Name ___________________________________________________________

Social Security Number ______________________________________________________

Address ___________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Telephone Number:__________________________________________________________

Campus: ___________________________________________________________________

Leave Period: From __________________________ To ________________________

Continue:

______ Health Insurance
The employee share of the biweekly premium must be paid for continuation of Health Insurance.

______ Dental & Vision
Dental and Vision will be continued without charge.

______ Basic Life Insurance
Basic Life continuation requires payment of the Foundation premium.

______ Optional Life Insurance
Optional Life Insurance continuation requires payment of the employee premium.

___________________________________ ________________
Employee Signature Date

FMLA Leave has been previously approved for the period indicated.*

* A copy of the approved Employee Request for Leave must be attached.

Rev. 2/98