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					COMMISSIONERS:                                                                        DOUGLAS BRUCE
DENNIS HISEY (CHAIR)                                                                     SALLIE CLARK
JIM BENSBERG (VICE CHAIR)                                                            WAYNE WILLIAMS

             EMPLOYEE BENEFITS AND MEDICAL SERVICES DEPARTMENT (EBMS)
          COMPENSATION, EMPLOYEE BENEFITS, MEDICAL SERVICES AND RISK MANAGEMENT DIVISIONS
                                           IMAD KARAKI
                                             DIRECTOR
                             MILITARY LEAVE OF ABSENCE

     1.     If I have been ordered by the Government to return to active military duty, and if the
            pay I will be receiving from the military is less than my current base pay with El
            Paso County, I may be eligible for pay differential. I understand that I must make
            written request for this pay differential in accordance with Chapter VI of the
            Personnel Policies and Procedures manual and submit to Finance/Payroll.

                I do          I do not            wish to submit written request for pay differential.

     2.     I understand that I may continue employee and dependent medical and dental
            coverage. If I elect to continue coverage, I understand that I must continue to
            contribute the Employee portion either through my military pay differential (if
            applicable), or I must remit payment to the County Finance office by the first
            business day of each month.

                I do          I do not          wish to continue Medical benefits.        not applicable

                I do          I do not          wish to continue Dental benefits.         not applicable

     3.     If I am currently enrolled in Cigna Voluntary Life insurance, I may have the option
            of continuing this benefit. An Application for Continuance needs to be completed
            and sent to Cigna Life within 31 days from the date of termination. The continuation
            form must be sent directly to the address noted on the bottom of the continuation
            form. Please contact EBMS for the Application.

     4.     If I am enrolled in the Flexible Spending Account, only receipts incurred up through
            my leave of absence start date will be considered for reimbursement. If I wish to
            continue participation in Flex, I must do so through COBRA. Information will be
            provided through the County’s COBRA administrator, Conexis. Eligible receipts
            must be submitted within 60 days after the end of the plan year.

     5.     If I have questions regarding my retirement benefits, I must contact the Retirement
            Office which is located at 105 E. Vermijo, Suite 200, phone number (719) 520-7490.

     I have received a copy of the Military Leave information contained in Chapter VI of the El Paso County
     Employee Personnel Policies and Procedures manual. I understand that I may be eligible to continue to
     employee benefits and this information has been explained to me. If I have any questions regarding my
     benefits, I will contact the Employee Benefits Administrator at (719) 520-7402.

     Name:                                                             S S #:
     Signature:                                                        Date:
     Department:                         Military Leave Effective Date:




          105 E. VERMIJO AVE., SUITE 111                     COLORADO SPRINGS, CO 80903
                  OFFICE: (719) 520-7402                     FAX: (719) 520-7497
                    WWW.ELPASOCO.COM                         IMADKARAKI@ELPASOCO.COM

				
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posted:2/27/2010
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