Leave Of Absence Application (Page 2 of 4) in pdf

5. Continuation of Pay

If applicable, you have the choice of taking an unpaid leave of absence or you may elect to

have accrued ESL, SBL, and/or PPL hours coordinated with California State Disability

Insurance (SDI) during the disability portion of your leave, as specified by TSRI’s

Administrative Guidelines. Once the disability portion of your leave has ended, you may

elect to be paid accrued PPL hours until the leave balance is exhausted or you return to

work. You may choose to apply for California Paid Family Leave (PFL). During this bonding

time, you must use two weeks of PPL or exhaust your PPL balance (whichever comes first)

before you are eligible to receive PFL benefits.

Please choose from the options below:

__ I choose to utilize my accrued ESL, SBL, and/or PPL hours during my leave.

__ I choose not to utilize my accrued ESL, SBL, and/or PPL hours during my leave.

__ N/A I am not eligible for ESL, SBL, and/or PPL accrual.

You are responsible for completing and submitting the SDI and PFL applications to the

California Employment Development Department (EDD).

These forms are available in

Human Resources, from your physician or the EDD.

6. Continuation of Benefits

Medical and Dental Insurance

Employer Contributions

If you are covered under TSRI’s medical and dental insurance plans, TSRI will

continue its normal contribution toward your medical and dental insurance premiums

for a maximum of 12 weeks during any Pregnancy-related Disability Leave taken

during the designated 12 month period.

Employee Contributions

While receiving pay from TSRI (ESL, SBL, or PPL), deductions for health benefit

coverage’s that were being made prior to the leave will continue. If a leave becomes

unpaid due to depletion of paid leave balances, deductions will accumulate in arrears

and will be deducted from the first paycheck(s) upon return to work.

Other Benefits

Voluntary Life Insurance, Long-Term Disability Insurance, Health Care Spending Account,

Dependent Life and Group Term Life benefits will continue for the length of the approved

Leave of Absence. Premiums for these benefits during the paid portion of the leave will

continue to be deducted from your payroll check.

If a leave becomes unpaid due to depletion of paid leave balances, deductions will

accumulate in arrears and will be deducted from the first paycheck(s) upon return to work.

Dependent Care Spending Account (DCSA) deductions will automatically cease during a

leave. When you return from leave, you may restart your DCSA by submitting a new Benefit

Coverage Change form to Human Resources within 31 days of your return.

Effective: 01/01/2017

Leave Of Absence Application Page 2