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:
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Medical
Dental
Employee Life Insurance
Dependent Life Insurance
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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:
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Medical
Dental
Employee Life Insurance
Dependent Life Insurance
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Health Care Reimbursement Account