Dartmouth College Application For Family/medical Leave Form printable pdf download

Dartmouth College Application For Family/medical Leave Form

DARTMOUTH COLLEGE

APPLICATION FOR FAMILY/MEDICAL LEAVE

Name: ________________________________Department:_____________________________

Current Address: _______________________________________________________________

Telephone: ______________________________Social Security Number___________________

Supervisor Name: _______________________________Hinman Box _____________________

Start Date of Anticipated Leave: ___________________________________________________

Expected Date of Return to Work: __________________________________________________

Will you be paid for vacation and/or personal leave during this time? If so, what dates_________

Will this leave be intermittent? Is so, what dates do you expect to be out of work?

_________________________________________________________________________

Reason for Leave (check one):

The birth of a child, or placement of a child with you for adoption or foster care; or

A serious health condition that makes you unable to perform the essential functions for your job; or

A serious health condition affecting _____your spouse, _____your child, _____your parent for whom you

are needed to provide care.

(Explain):_____________________________________________________________________

______________________________________________________________________________

Benefit Elections While on Unpaid Family/Medical Leave

BENEFIT ELECTIONS: If FML is approved, Dartmouth College continues your benefit credit.

You have the

option of continuing or canceling your benefits. Upon return from your leave, your cancelled benefits will be reinstated

automatically by the Benefits Office.

I wish to continue the following benefits during my leave:

□

Medical

Dental

Employee Life Insurance

Dependent Life Insurance

□

Health Care Reimbursement Account

Dependent Care Reimbursement Accounts cannot be continued while on leave according to IRS regulations.

I wish to cancel the following benefits during my leave: