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Employee Request for Leave of Absence Instructions

Learn more at eESIpeo.com or call 888.465.1171

A leave of absence is approved time o� from work. Leave may be paid or unpaid depending on your employer’s Leave of Absence policy. Leaves of absence may be granted for the following reasons: to care for a newborn or newly adopted child, to care for a seriously ill family member, employees’ personal medical condition, employees’ military service, employees’ education, employees’ government service, employees’ child, spouse or parent is called to active duty, employees’ care for covered service member with serious injury or illness incurred in active duty or for an employees’ personal reasons.

This leave of absence request form shall be used to request time o� from work, for all reasons except work related injuries. For work related injuries, please see your immediate supervisor or contact the eESI Risk Department at 888.465.1171.

When should I request a leave of absence?Employees may request a leave of absence for any reason listed above and with at least thirty (30) days advance notice, when practical.

When will my leave of absence begin?Most leave of absences will begin after the last day worked. After approval of the requested leave, most employers require that leave begin after accrued paid time o� (sick, vacation, or PTO) has been exhausted. If your employer does not require you to exhaust all paid time o�, please work with your manager to determine your last day of work.

Am I able to extend my approved leave period?Employees should contact their supervisor to request an extension, at least two weeks prior to the end of leave. Your employer will make the determination in granting an extension.

What if I do not return to work after the end of my leave period?Failure to report to work at the conclusion of leave without requesting and receiving an extension may be cause for termination of employment. Employees should check in while on leave and con�rm the return date as outlined in your company policy.

What type of documentation may be required for an approved leave of absence? If an employee’s leave is based on his or her serious health condition or that of a family member (parent, spouse, domestic partner, or child), he or she is required to have medical certi�cation from a health care provider. If an employee fails to provide such certi�cation, it may delay his or her leave. The employee must provide the certi�cation within 15 calendar days of the request.

What type of documentation is required for me to return to work?A return to work notice/doctors release is required for employees on leave for his/her own medical condition.

What happens to my insurance bene�ts while on a leave of absence?Employees enrolled in bene�ts should contact the eESI Bene�ts Department at 888.465.1171 for more information.

Is my job protected while I am on a leave of absence?Yes, if your leave quali�es for FMLA which means your employer is considered a covered employer, you, the employee, meet the eligibility requirements of FMLA, AND your reason for leave is an allowable reason under FMLA.If your leave does not meet all the FMLA requirements, your job is not protected. Job reinstatement is based on company policy and business needs. Discuss this with your manager when requesting a leave of absence.

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Inquiries at HR@eESIpeo.com or call 888.465.1171

PLEASE COMPLETE AND RETURN THIS FORM TO YOUR SUPERVISOR 30 DAYS IN ADVANCE OF LEAVE IF POSSIBLE

EMPLOYEE INFORMATION Employee Name (First, Last, Middle Initial)

Job Title/ Department Telephone number where you can be reached while on leave:

ABSENCE INFORMATION

This is a new request. This is an update to an existing request.

Requested Start Date:

Anticipated Return Date:

TYPE OF LEAVE Leave of Absence Intermittent Absence (information required below)

For Intermittent Absences, describe your intermittent or reduced work schedule (e.g., “up to 2-3 sick days a month per doctor”). This must be medically necessary and documented in a current medical certification form from your health care provider.

REASON(S) FOR LEAVE Please indicate the applicable reason(s) for your leave below. If you require additional information about leave types and their qualifying criteria,

please contact eESI at 1.888.465.1171 for more information.

For Employees Own Serious Health Condition (not work related)*

To Care for Ill Parent, Spouse, Child or Domestic Partner*

* For leaves due to your own or a Family Member’s Serious Health Condition, a Medical Certification form is required.

A completed Medical Certification form is attached.

I will submit a Medical Certification form within 15 days.

Workplace Injury / Worker’s Compensation (contact eESI at 1.888.465.1171 for more information)

Military Leave: Active Duty or Military Caregiver (contact eESI for more information)

Personal Leave (Non-Medical Reason)

LEAVE OF ABSENCE CATEGORIES A leave of absence may consist of leave without pay and/or paid leave (vacation, PTO, sick leave). Paid leave may be used in accordance with applicable policy/contracts. I request to use the following leave categories:

Type Number of Hours Dates: From Through Vacation

Sick Leave

Paid Time Off (PTO)

Leave w/o Pay

I have verified that I have sufficient accrued leave to take the above requested paid leave.

I hereby request a leave of absence from work as indicated above and certify that such leave is requested for the purpose(s) indicated. I understand that I must comply with my employer’s policy and procedure for requesting and returning from a leave of absence and provide documentation, including medical certification, if required. I further understand that I may be responsible for the cost of my insurance benefits and that it is my responsibility to contact the eESI benefits department to make arrangements for premium coverage, if applicable. Employee Signature: Date:

FOR COMPANY USE ONLY Supervisors please submit this completed form to your eESI HR Specialist.

Company has approved the above request for Leave of Absence beginning through .

Authorized Company Signature: Date:

Leave of Absence Request Form