Employer Leave of Absence Request Form

Leave of Absence Request Form

*If you are a Company representative completing this form on behalf of an employee, please provide this information when contacting our Leave of Absence Department. If you have questions or would like assistance with filling out this form, please contact the G&A Leave of Absence Department by phone at 1-866-497-4222.
If prefer the employee complete the form, please share the link below.

Employee Leave of Absence Request Form
Company Name*
Full Employee Name*
Preferred Pronouns
Employee Home Address
Street address, City, State, Zip Code
Employee Worksite Location & State*
Indicate if they work remotely
Employee Regular Workdays*
Employee Regular Work Hours*
Employee Personal Phone Number*

Area CodePhone Number
Employee Personal Email Address*
example@example.com
Employee Preferred Contact Method
Employee Temporary Contact Address
e.g., temporary residence while caring for a family member
Leave Start Date*

MonthDayYear
Date
Estimate Leave End Date

MonthDayYear
Date
Please select what leave frequency they are requesting*
Is the employer aware of their Leave request?*
Will they use accrued Paid Time Off (PTO) while on leave?*
If yes, please specify dates and number of hours used each day.
Family and Medical Leave ActState Mandated LeavePersonal Leave of AbsenceCompany Provided Leave PolicyMilitary Leave
FMLA is federal law. Eligibility: Must work for a covered employer, be employed for at least 12 months, worked a minimum of 1,250 hours during the 12-months immediately preceding the start of leave, and work at a worksite location with 50 or more employees within a 75-mile radius.
State Name*
Will they be applying for state wage replacement?
Bonding Leave: the birth, adoption, or foster care of your child within 12 months following birth or placement of the child;Family Care Leave: to care for a covered family member (based on leave type) with a serious health condition;Your own Serious Health Condition: The inability to work because of a serious health condition; Includes medical conditions related to pregnancy and childbirth.Military Emergency Leave: a “qualifying exigency,” as defined under the FMLA or other state- mandated leave, for military operations arising out of a covered family member’s active duty or call to active duty as a member of the military reserves or National Guard in support of a “contingency operation” declared by the U.S. Secretary of Defense, President, or Congress, as required by law;Military Caregiver Leave: to care for a covered family member, (as defined in the applicable law), who is a member of the Armed Forces (including military reserves and National Guard) undergoing medical treatment, recuperation, or therapy, is in an outpatient status, or is otherwise on the temporary disability retired list- with a serious injury or illness incurred in the line of duty while on active duty that may render the individual medically unfit to perform his or her military duties.
Signature

Clear
Should be Empty: