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.
Request for Leave of Absence
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.
*Reason for leave:
Between Assignments – Intend to return
*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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