Letter To Employee To Initiate Fmla/cfra Leave printable pdf download

[COMPANY]

LETTER TO EMPLOYEE TO INITIATE FMLA/CFRA LEAVE

Date:

Dear _________:

Re:

Notice of FMLA/CFRA Eligibility, Rights and Responsibilities, and Designation of

Leave

The purpose of this letter is to notify you about your eligibility for Family Medical Leave Act

(FMLA) and California Family Rights Act (CFRA) leave.

A. Notice of Eligibility

On ________ you informed us of your need for a leave of absence beginning on ________ for

your own serious health condition. In general, to be eligible for FMLA/CFRA leave an

employee must have worked for an employer for at least 12 months, have worked at least 1,250

hours in the 12 months preceding the leave, and work at a site with at least 50 employees within

a 75-mile radius. This notice is to inform you that you are eligible for FMLA/CFRA leave.

Additional rights and responsibilities are described below.

B. Rights and Responsibilities for Taking FMLA/CFRA Leave

You are eligible for up to 12 weeks of unpaid leave in a 12-month period measured forward from

the date of your first FMLA leave usage. As explained above, you meet the eligibility

requirements for taking FMLA/CFRA leave. You have previously used _____ weeks of

FMLA/CFRA, and therefore, you have __________ weeks of leave available to you in the

applicable 12-month period. You will be required to use your accrued, unused paid time

off/vacation during your FMLA/CFRA absence.

Your health benefits will be maintained during this 12-week period under the same conditions as

if you continued to work. While on your FMLA/CFRA leave you will be responsible for

contacting _______ at ______ to make arrangements to continue to make your share of the

health insurance premiums in order to maintain health benefits while you are on leave. The

amount of your payment will be ________. You have a minimum 30-day grace period in which

to make premium payments. If payment is not made on time, your group health insurance may

be cancelled, provided we notify you in writing at least 15 days before the date your health

coverage will lapse, or, at our option, we may pay your share of the premiums during your

FMLA leave and recover these payments from you upon your return to work. If you do not

return to work following FMLA/CFRA leave for a reason other than: 1) the continuation,

recurrence, or onset of a serious health condition which would entitle you to FMLA leave; 2) the

continuation, recurrence, or onset of a covered service member’s serious injury or illness which

would entitle you to FMLA leave; or 3) other circumstances beyond your control, you may be

required to reimburse us for our share of the health insurance premiums paid on your behalf

during your leave.

P•A•S Associates has expertise in human resources and other areas involving employment issues. P•A•S Associates, in providing this form, does not represent that it

is acting as an attorney or that it is giving any form of legal advice or legal opinion. P•A•S Associates recommends that before making any decision pertaining to

human resource issues or employment issues, including the utilization of information contained on this website, the advice of legal counsel to determine the legal

ramifications of the use of any such information be obtained.P•A•S Rev. 03/11

Letter To Employee To Initiate Fmla/cfra Leave

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