首页 » 工具箱 » Sample Forms » Benefits » Sample Form for Employee’s FMLA Request – Continuous
文件名: Sample Form for Employee’s FMLA Request – Continuous
文件大小: 30 KB
文件语言版本: English
文件类型:
Word
文件说明: It is my understanding that I am eligible for up to 12 weeks of leave per year under the Family Medical Leave Act and that I will be reinstated to my job after my leave. [If you are covered by your employer’s health insurance include this sentence: “I understand that [Employer’s Name] will continue my health insurance during my leave as per the regulations.”] It is also my understanding that when a health care provider certifies a need for FMLA leave for a period exceeding 30 days, an employer may not require additional certifications during that period unless a request is made to extend the leave, circumstances change significantly or the employer receives information that casts doubt on the need for leave. (See 29 C.F.R. 825.308(b)(2)).
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