Leave Of Absence / Benefit Continuation Form - 2005

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RICE UNIVERSITY
LEAVE OF ABSENCE / BENEFIT CONTINUATION FORM
Name of Person on Leave ____________________________________________
Today’s Date _________________________
Department _______________________________________________________
Employee ID _________________________
Home Address ____________________________________________________
Position Number ______________________
(if different)
____________________________________________________
Telephone ___________________________
Type of Leave:
Work Related Injury
Medical
Family
Personal
Sabbatical
Jr. Faculty
Prof./Edu.
Comments: _______________________________________________________________________________________________
Medical, Personal, Family, Unpaid or Worker’s Compensation Leaves:
For HR Use Only
Time Eligible
Date From
Date To
Leave Status
Paid Benefit Time
_____________
Days or
Hours
_____________
_____________
_____________
Paid Short Term Disability
_____________
Days or
Hours
_____________
_____________
_____________
Unpaid or Worker’s Compensation
_____________
_____________
_____________
Sabbatical, Jr. Fac., or Paid Professional Leaves:
For HR Use Only
Annual Rate
Date From
Date To
Leave Status
Paid Leave:
Full Pay
_____________
_____________
_____________
_____________
Half Pay
_____________
_____________
_____________
_____________
Other Pay
_____________
_____________
_____________
_____________
Charge to (if different from regular labor distribution):
Date From
Date To
Fund
Organization
Account
Program
%
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
I understand that this leave of absence, if granted, is governed by applicable University policies and is subject to the following
conditions:
a)
Paid Leaves: The University pays its usual portion of insurance payments for a maximum of 12 months, inclusive of all leaves. If
you do not wish to continue your University insurance, arrangements to terminate your insurance will need to be made with Human
Resources. Contributions to the Retirement Plan are solely based on compensation paid by Rice during the leave.
b)
Unpaid Leaves: Arrangements to have the University continue benefits during unpaid leaves should be made with Human
Resources prior to the leave. The University also pays its usual portion of insurance payments for the first 12 months of an unpaid
leave. No contributions are made to the Retirement Plan when on unpaid leave.
c)
Failure to pay insurance premiums will result in cancellation of your University insurance.
d)
Medical Leaves: Applicants must provide a letter from a doctor stating the need for the leave and the estimated duration of the
leave before the leave can be granted. A doctor’s note stating ability to return to work must be provided before work can resume.
e)
With the exception of the first 12 weeks of family/medical leaves, the period during which the University contributes to benefits is
considered part of the COBRA continuation period.
f)
Benefit time and holidays do not accrue during a leave of absence, including leaves paid under the short-term disability program or
Worker’s Compensation program.
__________________________________________________________________________
_______________________
Signature of Applicant/Authorized Representative
DD-MON-YY
____________________________________________________
____________________________________________________
Recommended by: Supervisor/P.I.
DD-MON-YY
Approved by: Dean/Vice President
DD-MON-YY
____________________________________________________
____________________________________________________
Recommended by: Department Chair/Director
DD-MON-YY
Reviewed by: Human Resources
DD-MON-YY
CHANGE REASON (for HR use only): __________________
Forward original form to Human Resources. If desired, make a copy for employee and your records.
05/18/2005

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