Basic Plan Option High Plan Option Mid Plan Option Employee Request for Leave of Absence Instructions Learn more at eESIpeo.com or call 888.465.1171 A leave of absence is approved time off from work. Leave may be paid or unpaid depending on your employer’s Leave of Absence policy. Leaves of absence may be granted for the following reasons: to care for a newborn or newly adopted child, to care for a seriously ill family member, employees’ personal medical condition, employees’ military service, employees’ education, employees’ government service, employees’ child, spouse or parent is called to active duty, employees’ care for covered service member with serious injury or illness incurred in active duty or for an employees’ personal reasons. This leave of absence request form shall be used to request time off from work, for all reasons except work related injuries. For work related injuries, please see your immediate supervisor or contact the eESI Risk Department at 888.465.1171. When should I request a leave of absence? Employees may request a leave of absence for any reason listed above and with at least thirty (30) days advance notice, when practical. When will my leave of absence begin? Most leave of absences will begin after the last day worked. After approval of the requested leave, most employers require that leave begin after accrued paid time off (sick, vacation, or PTO) has been exhausted. If your employer does not require you to exhaust all paid time off, please work with your manager to determine your last day of work. Am I able to extend my approved leave period? Employees should contact their supervisor to request an extension, at least two weeks prior to the end of leave. Your employer will make the determination in granting an extension. What if I do not return to work after the end of my leave period? Failure to report to work at the conclusion of leave without requesting and receiving an extension may be cause for termination of employment. Employees should check in while on leave and confirm the return date as outlined in your company policy. What type of documentation may be required for an approved leave of absence? If an employee’s leave is based on his or her serious health condition or that of a family member (parent, spouse, domestic partner, or child), he or she is required to have medical certification from a health care provider. If an employee fails to provide such certification, it may delay his or her leave. The employee must provide the certification within 15 calendar days of the request. What type of documentation is required for me to return to work? A return to work notice/doctors release is required for employees on leave for his/her own medical condition. What happens to my insurance benefits while on a leave of absence? Employees enrolled in benefits should contact the eESI Benefits Department at 888.465.1171 for more information. Is my job protected while I am on a leave of absence? Yes, if your leave qualifies for FMLA which means your employer is considered a covered employer, you, the employee, meet the eligibility requirements of FMLA, AND your reason for leave is an allowable reason under FMLA. If your leave does not meet all the FMLA requirements, your job is not protected. Job reinstatement is based on company policy and business needs. Discuss this with your manager when requesting a leave of absence.