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					                       County of Albemarle
                       Local Government & Public School Division
                       Department of Human Resources
                       401 McIntire Road, Room 125
                       Charlottesville, VA 22902-4596
                       (434) 296-5827; Fax (434) 296-5828




Dear Colleague,

Enclosed you will find information regarding the usage of the Sick Leave Bank.
Following is a summary of the enclosed items:

           Sick Leave Bank Policy – This is the Sick Leave Bank Policy that governs the
           usage and accessibility of the Sick Leave Bank.

           Sick Leave Bank Withdrawal Request - This form will need to be filed with the
           Human Resources Department prior to actually drawing leave from the Bank.
           You should work with the individual in your department who is responsible for
           the leave reports to determine the effective date.

           Physician’s Letter - This form will need to be completed by the attending
           physician and returned to the Human Resources Department prior to drawing
           leave from the Bank.

           Release to Return to Work Form - This form is to be completed by the
           attending physician. This form is to be completed at the end of your illness before
           you return to work.

You may be using the Sick Bank program in conjunction with Family Medical Leave
(FMLA). If you need FMLA information, please notify our office.

Please feel free to call your contact person in the Human Resources Department at (434)
296-5827 if you have questions or concerns.

Regards,

The Benefits Team




Sick Leave Bank Cover Letter.doc (09/06) Recycle previous copies
                                            Sick Leave Bank Policy
The County will maintain a Sick Leave Bank to be used when a member of the Bank becomes incapacitated by long-
term illness or injury (defined as 20 or more days) as long as one-third of the eligible members agree to participate in
accordance with the terms contained therein. Membership shall be voluntary and open to all employees who accrue
Sick Leave. Each employee of the Board who accumulates sick leave is eligible for membership and may become a
member by donating one day of Sick Leave upon joining and an additional day thereafter whenever an assessment is
required. Upon termination of employment or membership in the Bank, a participating employee may not withdraw
the days he/she contributed to the bank.
Requests for leave time from the Bank must be made in writing by the employee (or his representative if the employee
is unable to submit the request) in advance of the absence for which the extra days are to be granted. Requests cannot
be made retroactively except in the case of absences that were presumed to be covered by Workers’ Compensation, but
were subsequently denied. Requests must be supported by a medical doctor’s certificate acceptable to the County. The
County reserves the right to require additional medical documentation to support the request.

A.     Enrollment Procedures

       An eligible employee may enroll within the first thirty (30) days of employment. An employee who does not
       enroll when first eligible may do so during any subsequent Benefits Open Enrollment period by making
       application and providing satisfactory evidence of good health to the Board. Membership in the Bank may be
       earned by contributing one (1) day of Sick Leave upon joining and an additional day thereafter whenever an
       assessment is required. The donated days of leave will be deducted from the donor’s accumulated days of Sick
       Leave.


B.     Rules for Use

       1.    The first twenty (20) consecutive working days of an illness or disability will not be covered by the Bank,
             but must be covered by the member’s own accumulated paid leave or leave without pay. This
             requirement may be met in cases in which twenty (20) days of absence for the same illness/injury,
             although not consecutive, occur within thirty (30) working days.

       2.    Eligible employees may take a maximum of forty-five (45) working days from the Sick Leave Bank in
             any rolling year (defined as a three hundred sixty-five (365) day period beginning with the first day of
             Sick Leave Bank usage).

       3.    Days drawn from the Bank for any one period of eligibility must be consecutive, except additional
             periods of disability resulting from recurrence or relapse of the original illness which will be covered
             fully on a continuing basis up to the annual maximum of forty-five (45) days. Once a member has used
             all forty-five (45) days of Sick Leave Bank, he must return to work and must meet the requirements of
             Section B.1 before becoming eligible to utilize Sick Leave Bank benefits again.

       4.    A member of the Bank will not be able to use Sick Leave Bank benefits until the employee’s Sick Leave
             balance declines to zero. Sick Leave and/or Sick Leave Bank Leave will run concurrently with FMLA
             where applicable.

       5.    Members of the Bank will be assessed additional days of Sick Leave at such time as the Bank is depleted
             to two hundred (200) days, unless they choose not to participate further in the Bank. Members who have
             no Sick Leave to contribute at the time of assessment will be assessed one (1) day and allowed to
             temporarily maintain a negative balance.

       6.    Members utilizing Sick Leave days from the Bank will not have to replace these days except as a regular
             contributing member of the Bank.

       7.   The Sick Leave Bank request form must be signed by a medical doctor (M.D.) acceptable to the County.
            The County reserves the right to require additional medical documentation supporting the request.

C.     Termination

             Upon termination of employment or membership in the Sick Leave Bank, a participating
             employee may not withdraw the days he has contributed to the Bank.
                                     County of Albemarle
                                  Human Resources Department


                                     Sick Leave Bank
                                    Withdrawal Request


Full Name: ______________________________________________________________

Position:__________________________________________________________

School/Department:__________________________________________________


I hereby request withdrawal of days from the Albemarle County Sick Leave Bank. My
disability is due to
__________________________________________________________________________________________________
_
                                          (State reason)



A physician’s statement certifying my disability is attached.


_______________________________________________                        _______________________________
             (Employee Signature)                                                   (Date)




                                   (For Human Resources Use Only)




     •    Employee is a member:                                  YES          NO

     •    Physician’s statement attached:                        YES          NO

     •    Approval granted:                                      YES          NO

     •    Date withdrawal of days will become
          effective:__________________________



_______________________________________________                        _______________________________
         (Authorized Human Resources Signature)                                     (Date)




Sick Bank Withdrawal Request (08/2008) Recycle previous copies
                  County of Albemarle
                  Local Government & Public School Division
                  Department of Human Resources
                     www.albemarle.org
                  401 McIntire Road, Room 125
                  Charlottesville, VA 22902-4596
                  (434) 296-5827; Fax (434) 296-5828




Dear Physician:

The employee named below is applying for time from the Albemarle County Sick Leave Bank.
Eligibility for this leave is based on the amount of time needed off work for medical reasons only. In
order to determine his/her eligibility to receive this benefit, we need the information requested
below. Thank you for your cooperation.

To be completed by employee:

Full Name_____________________________________________________________________

Job Title: ______________________________ Department: ____________________________

Work phone__________________________________                        Home phone___________________


To be completed by physician:

DIAGNOSIS:


BRIEF EXPLANATION:



DATE DISABILITY BEGAN: _______________________________________

EXPECTED DATE TO RETURN TO WORK: ________________________

RESTRICTIONS FOR LIGHT DUTY (if applicable):



                            Physician's signature:__________________________________

                                                 Date:   __________________________________


SLB-PHYS.LTR (08/2008) Recycle previous copies
     ALBEMARLE COUNTY RELEASE TO RETURN TO WORK


Patient’s Name:___________________________________________________________

Date the “serious health condition” of the patient started:_________and ended:_______

Date the EMPLOYEE is approved to return to work:_____________________________


                                   IF APPLICABLE

 Restrictions or Limitations? ______None        ______Schedule     ______Activity

 Nature of Restrictions or Limitations:




 Expected to return to full function:   ______YES     or    ______NO



I have examined the employee and can certify to the best of my knowledge, and within
the limitations, if any listed above, that the patient named here is, or on the approved
return date will be, able to resume working and perform all the essential functions of
his/her job.


______________________________________                     ________________________
Physician’s Signature                                      Date


                                   Please return to:
                                 County of Albemarle
                            Department of Human Resources
                                  401 McIntire Road
                              Charlottesville, VA 22902
                                    (434) 296-5827
                                                            Enrollment/Change Form - County of Albemarle
 A. EMPLOYER INFORMATION (To be completed by Employer)
 Group No.                                              Group Name                                          Effective Date                     Employer’s Signature                                                          Date
                                                                       County of Albemarle
 B. SUBSCRIBER INFORMATION (To Be Completed by Employee)
 THE SOUTHERN HEALTH PLAN YOU ARE CHOOSING IS POINT OF SERVICE (POS) (PLEASE CHECK ONE)                                                  High Option         Middle Option           Low Option
 COVERAGE TIERS: (PLEASE CHECK ONE)                         Employee Only                     Employee + 1 Child                         Employee + Children                     Employee + Spouse                  Employee + Family
PLEASE MAKE THE FOLLOWING CHANGES: Please include supporting documention for the change.
                                                                                                                                                                                                                       TYPE OF GROUP
ENROLL                                                  CHANGE                                                                                        TERMINATE COVERAGE                                               Please check one:
  Open Enrollment                                         Add Individual (reason for addition) _______________________                                  Cancel Coverage (reason) _________________                       SCHOOL
  New Hire (date of hire) _________________________       Delete Individual (reason for deletion) _____________________                                 Last Date of Employment __________________                       LOCAL GOV
                                                                                                                                                                                                                         RETIREE
  COBRA (date of eligibility) ______________________      Name Change (previous name) __________________________                                                                                                         CATEC
  Qualifying Event (description/date) _________________   Physician Change                     Address Change                                                                                                            REGIONAL JAIL
                                                                                                                                                                                                                         SERV AUTH
 LAST NAME                                                             FIRST NAME                                            MI   M/F BIRTHDATE                          SOCIAL SECURITY NO.                             COBRA
                                                                                                                                                                                                                         BRJD
                                                                                                                                                                                                                       MARITAL STATUS
 ADDRESS                                                                                                                     PRIMARY CARE PHYSICIAN                                                                    Please check one:
                                                                                                                                                                                                                         SINGLE/WIDOWED
                                                                                                                                                                                                                         MARRIED
 CITY                                                                  STATE            ZIP                                  WORK/DAY PHONE                         HOME PHONE                                           DIVORCED

C. INDIVIDUAL MEMBERS TO BE COVERED OR DELETED
                                                                                                                                                                                                                                      CURRENT
ENROLL OR DELETE          FULL NAME (LAST, FIRST, MI)                                 SEX      RELATIONSHIP              BIRTHDATE                SOCIAL SECURITY #                         PRIMARY CARE PHYSICIAN                     PATIENT?

   E          D                                                                        M/F                                                                                                                                               Y    N


   E          D                                                                        M/F                                                                                                                                               Y    N


   E          D                                                                        M/F                                                                                                                                               Y    N


   E          D                                                                        M/F                                                                                                                                               Y    N


D. Is your spouse a County employee?                                No         If Yes, complete the following:
 NAME                                                                                                                                      SOCIAL SECURITY NO.


 E. CONDITIONS OF ENROLLMENT
 I hereby apply for membership or request a change in membership in this Southern Health Services, Inc. (Southern Health)/Coventry Health and Life Insurance Company (CHLIC) Plan. I understand that my enrollment and benefits
 are in accordance with those described in the applicable Description of Benefits and Group Agreement or Group Policy. I authorize 1) all health providers and insurers to furnish Southern Health/CHLIC, and 2) all health providers and
 Southern Health/CHLIC to furnish all insurers and health providers records concerning me or any of my covered individuals for whom information is requested for any purpose required for the coverage of benefits including, but not
 limited to, the coordination of payments with other insurers or in connection with the provision of medical care. I understand that I or my authorized representative is entitled to receive a copy of this form containing this authorization
 for disclosure of information. A photographic copy of this authorization shall be valid as the original. I authorize my employer to deduct from my wages the amount required (if any) to cover my contribution for coverage. I certify that all
 the above information is correct. For claim adjudication purposes, this authorization is valid for the duration of my coverage for health benefits through Southern Health/CHLIC. For purposes of collecting information for an insurance
 policy application, policy reinstatement, or a request for change in policy benefits, this authorization shall remain valid for thirty months from the date the authorization is signed.
I HAVE READ AND AGREE TO THE CONDITIONS OF ENROLLMENT.

Employee Signature                                                                                                                                                                                   Date

F.     OTHER INSURANCE Do you or your covered individuals have other coverage?                                                         No If Yes, complete back page.
SH.EF.ALBCNTY.05-06
 List all individuals covered by the subscriber with medical health insurance in addition to Southern Health Services, Inc. (Southern Health) or Coventry
 Health and Life Insurance Company (CHLIC).
 POLICY HOLDER                                                BIRTHDATE                 EMPLOYER                                                        INSURANCE COMPANY


 LIST INDIVIDUALS COVERED                                                                                                EFFECTIVE DATE               CONTRACT NO./GROUP NO.


 Do you or your covered individuals have Medicare Coverage?      Yes      No    If Yes, please complete the following:


 NAME                                                         MEDICARE ID NO.                                                 PART A EFFECTIVE DATE                 PART B EFFECTIVE DATE


 NAME                                                         MEDICARE ID NO.                                                 PART A EFFECTIVE DATE                 PART B EFFECTIVE DATE




SH.EF.ALBCNTY.05-06