Leave of Absence Request Form


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									Employee Leave Request
This Employee Leave Request is used by an employee when requesting a leave of
absence from work. It is important to properly document employee leave requests in
writing. The employee simply fills out this form and specifies the reason for leave, the
leave dates, health and dental coverage, and more. In addition, the employer can add
any additional lines to this form as required. This form is ideal for small businesses that
want to provide employees with a clear and organized method for requesting time off.
                                    Employee Leave Request

Any unpaid absence lasting longer than 5 calendar days qualifies as a Leave of Absence
(LOA). All LOA’s must be requested in advance, and approved by Management.

If you would like to request leave under the FMLA, please consult with Accounting.
This form is NOT to be used for FMLA requests.

The following information is necessary to be considered for a LOA. Please complete,
sign, and return this form to your Supervisor or Placement Consultant as far in advance as
possible, but not less than 7 calendar days before the absence is to begin.

Name: _______________________________________________________

Position: _____________________________________________________
*Reason for leave:
    Jury Duty
    Military Leave
    Extended Vacation
    Between Assignments – Intend to return
    Other: ________________________________________________
*Attach documentation that justifies leave (i.e.; Military Orders, Jury Duty Notice, etc)

LOA Start Date: ____________ Date of return from LOA: _____________

Is Health/Dental coverage to be continued during leave?

        If YES, your premiums due during the time of absence will be deducted from the
         paycheck occurring closest to the beginning of leave.

        If NO, coverage will cancel at the end of the month. COBRA will be available
         and notices will be sent according to federal guidelines. Upon your return to
         Company, you may re-qualify for coverage after the designated waiting period.

____________________________________________            ___________________________________________
Employee Signature / Date                               Supervisor Signature / Date

While every effort will be made to return employees to the same position after LOA, this cannot be
guaranteed. Priority will be given to the business needs of Company. Another suitable position with
similar wages and duties may be considered, if available.

                                          For Office Use Only


Health Premium Due _________________ Dental Premium Due ________________

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