Leave Of Absence Approval Form (Page 2 of 2) in pdf

Leave Of Absence Approval Form Page 2

may be contacted at the following address and phone number:

Address _______________________________________________________________________

______________________________________________________________________________

Telephone No. __________________________________

I understand I may not work while on leave, except as part of an approved rehabilitation program and that I am to

comply with applicable company policies, such as confidentiality and conflict of interests. I understand failure to

comply with applicable policies may lead to discipline.

HEALTH COVERAGE

? do

? do not wish to continue my current group health insurance coverage (if no block is checked,

health coverage will continue as long as premiums are timely paid). I understand that contributions are due in full on

the first day of each month and that failure to pay my monthly contributions may result in the termination of coverage

for me and my dependents. I also acknowledge that it is my responsibility to notify the benefits department in writing

of any changes in my coverage in accordance with the procedures outlined in my benefit handbook.

I understand no benefits accrue during my leave.

Nothing herein creates a contract between the company and any person for employment or entitlement to benefits.

No commitments regarding employment or continuation of these benefit programs are made herein.

Employee's Signature_______________________________________ Date___________________

Approvals:

Dept. Head (Printed) ______________________________________________

Dept. Head Signature _____________________________________________

Original: Personnel File

Copy: Employee

Leave Of Absence Approval Form Page 2