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 ______________________________________________________
Leave Period: From __________________________ To ________________________
______ 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.