5. (a) If you normally pay a portion of the premiums for your health insurance, these payments will continue during
the period of FMLA leave. Arrangements for payment have been discussed with you, and it is agreed that
you will make premium payments as follows: (Set forth dates, e.g., the 10th of each month, or pay periods,
etc. that specifically cover the agreement with the employee.)
(b) You have a minimum 30-day (or, indicate longer period, if applicable) grace period in which to make premium
payments. If payment is not made timely, your group health insurance may be cancelled, provided we notify
you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may
pay your share of the premiums during FMLA leave, and recover these payments from you upon your return
to work. We
will not pay your share of health insurance premiums while you are on leave.
will not do the same with other benefits (e.g., life insurance, disability insurance, etc.)
while you are on FMLA leave. If we do pay your premiums for other benefits, when you return from leave you
will not be expected to reimburse us for the payments made on your behalf.
will not be required to present a fitness-for-duty certificate prior to being restored to
employment. If such certification is required but not received, your return to work may be delayed until
certification is provided.
7. (a) You
are not a “key employee” as described in § 825.217 of the FMLA regulations. If you are a
“key employee:” restoration to employment may be denied following FMLA leave on the grounds that such
restoration will cause substantial and grievous economic injury to us as discussed in § 825.218.
have not determined that restoring you to employment at the conclusion of FMLA leave
will cause substantial and grievous economic harm to us. (Explain (a) and/or (b) below. See §825.219 of
the FMLA regulations.)
While on leave, you
will not be required to furnish us with periodic reports every
(indicate interval of periodic reports, as appropriate for the particular leave situation)
of your status and intent to return to work (see § 825.309 of the FMLA regulations). If the circumstances of
your leave change and you are able to return to work earlier than the date indicated on the reverse side of
this form, you
will not be required to notify us at least two work days prior to the date you
intend to report to work.
will not be required to furnish recertification relating to a serious health condition. (Explain
below. if necessary, including the interval between certifications as prescribed in §825.308 of the FMLA
This optional use form may be used to satisfy mandatory employer requirements to provide employees taking FMLA leave with written notice
detailing specific expectations and obligations of the employee and explaining any consequences of a failure to meet these obligations.
(29 CFR 825.301(b).)
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.
Public Burden Statement
We estimate that it will take an average of 5 minutes to complete this collection of information, including the time for reviewing instructions.
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you
have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden. send them to the Administrator, Wage and Hour Division, Department of Labor, Room S-3502. 200 Constitution Avenue, N.W.,
Washington. D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THE OFFICE SHOWN ABOVE.