Family And Medical Leave Act (Fmla) Medical Certification Form Page 8
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912-2012
Fax Cover Sheet
Employees please ensure to send the FMLA forms to
:
.
Verizon
Absence Reporting Center
500 Summit Lake Drive 3rd Fl
Valhalla, NY 10595
FAX 1-877-786-4500
Employee Name: __________________________
EMPLID: ___________________
First Day of Absence: ________________
Date: ______________________________
Fax#:______________________________
From: ______________________________
Pages including cover sheet: ___________
CONFIDENTIAL AND PRIVATE
Please fax the completed forms to the correct processing center.
Page 8 of 9
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Parent category: Business