This Leave of Absence Request Form is used by an employee when requesting to take a leave of absence. When an employee takes a leave of absence, it is important to document the event in their employment file. This form contains the essential information that should be included in a request for leave of absence including the reason for leave, the start date and date of return, and health insurance information. This document can be used by any company's accounting department or an employee requesting a leave of absence.
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 Approval______________________________________________________________ Health Premium Due _________________ Dental Premium Due ________________ © Copyright 2015 Docstoc Inc. registered document proprietary, copy not 2
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