Employee Request For Leave Form Page 2
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2Part II: Employee Entitlement and Certification
I understand that:
•
To be eligible for FMLA leave, I must have completed one year of service and have worked a minimum of
1250 hours during the 12 month period prior to my leave
During my period of leave, my group medical, dental and vision coverage will continue at the same level
•
and under the same provisions that are in effect at the time leave begins and that I am fully responsible for
my portion of the premium(s) one month in advance. If I fail to remit my premium within the required
period, my coverage will cease as of the first of the month for which payment is past due
•
I am responsible for notifying the Research Foundation immediately of any change(s) in the leave period
Upon return from FMLA leave, I am entitled to be restored to my former position or an equivalent one,
•
with equivalent pay, benefits and terms of employment, provided I am not a key employee under FMLA
definition whose restoration would cause the Research Foundation to suffer substantial and grievous
economic injury
Employee’s Signature: _________________________________ Date: ______________
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