State Disability Insurance Benefits - DOC

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					                        State of California              State and Consumer Services Agency                                 Arnold Schwarzenegger, Governor

                        DEPARTMENT OF GENERAL SERVICES
                        M a n a g em e nt S er vi c es D i visi o n                             O f fi c e o f H um a n R e so u r c es
                        P.O. Box 989052, 707 3rd Street, 7th Floor, West Sacramento, CA 95798-9052•(916) 376-5400•FAX (916) 376-5393•www.dgs.ca.gov



          STATE DISABILITY INSURANCE & PAID FAMILY LEAVE EMPLOYEE OPTIONS CHECKLIST
                           (Complete your portion of this form, print, sign and give to your supervisor for signature)
NAME (Last, First MI)                                                                                              CBID:

SSN (Last Four Digits Only):                                                  HOME PHONE :                         ABMS ID:

                                                                 LEAVE OF ABSENCE
BEGINNING DATE:                                                           ENDING DATE:

Below is a list of options that are available to you. Please make your election, attach your medical substantiation and
return this form no later than seven days from date of disability. Failure to do so may result in the loss of coverage:

OPTION A:
I choose to request a medical leave of absence while on SDI                              - PFL         (leave due to pregnancy                    ) and:

     1)        I elect to use my leave credits to cover the seven (7) day SDI/PFL waiting period. Please indicate the leave
           type and amount of leave you would like to use.
              Sick # of hours              Vacation # of hours                PH # of hours            CTO # of hours
              Excess # of hours            Holiday Credit # of hours           Other (identify type     ) # of hours

     2)        I elect to use my leave credits to cover the seven (7) day SDI/PFL waiting period AND continue to use leave
           credits through the following date before electing to receive SDI Benefits.
              Sick # of hours              Vacation # of hours                 PH # of hours         CTO # of hours
              Excess # of hours            Holiday Credit # of hours           Other (identify type    ) # of hours
           Date leave credits paid through         .

     3)      I elect to use the following leave credits to supplement my SDI/PFL benefit (max of 40 hours per pay period).
            Sick # of hours                Vacation # of hours                 PH # of hours           CTO # of hours
            Excess # of hours              Holiday Credit # of hours           Other (identify type      ) # of hours
The employee must provide the HR office copies of the following documents to ensure proper leave credit
supplementation:
      SDI/PFL check stubs
      SDI/PFL Notice of Computation from EDD
WHEN OPTIONS CHECKLIST IS RECEIVED IN PTU NO CHANGES WILL BE ALLOWED FOR SUPPLEMENTATION
OPTION B:
I choose NOT to be on SDI and:
     I am requesting a paid leave of absence and I will use leave credits to cover the period from          to        .
    (A leave plan is required).
     I am requesting an unpaid leave of absence from                     to            . I am aware that I am fully responsible
for the payment of full premiums for any insurance in which I am enrolled.
OPTION C:
     I choose to work while on SDI and: will be working approximately            days or hours per week.
HEALTH BENEFITS              I elect to continue my health benefits, I understand when I return upon my return or separation I
will be responsible for repayment of the employee’s portion of the health insurance premium. Initial here ______
                             I choose not to continue my health benefits
                        TO BE COMPLETED BY ATTENDANCE CLERK OR SUPERVISOR
Leave credits available as of:
Sick Leave         Vacation/Annual Leave Personal Holiday      PLP/2003, VPLP                                                                     CTO      Excess
       Other (Specify type)      ;
Employee’s Signature              Date:     Supervisor’s Signature                                                                           Date:
__________________________ _____________ ___________________________                                                                         ___________________




Revision 7/10       The Ziggurat  707 Third Street, Suite 7-130  PO Box 989052  West Sacramento, CA 95798-9052  (916) 376-5400

				
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