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

Leave Of Absence Application Page 4

I have read the terms and conditions for a LOA contained in all four pages of this application

and understand and agree to my obligations. I recognize that I am responsible for my benefit

premiums as defined in the application and realize that failure to make payment will result in

loss of coverage for myself and my dependent(s). I authorize TSRI to deduct the necessary

insurance premiums from my paycheck(s) upon my return to work if I should go unpaid

during my leave.

I understand that if I wish to add my newborn to TSRI’s medical plan, I must do so within 31

days of the date of birth. I understand that if I do not add my newborn child to the medical

plan within 31 days, I will not be able to do so until the next Open Enrollment period with the

effective date of coverage January 1 of the following plan year. “Benefit Coverage Change

Forms” may be requested from Benefits Administration.

Employee's Signature

Date

Supervisor's Signature

Date

For additional information about your Pregnancy Disability Leave rights and responsibilities,

please visit TSRI’s Leave of Absence Administrative Guideline at

, or make a request for a hard copy.

For questions regarding leave of absence, call Benefits Administration at 858-784-

8487.

California Employees, please return completed LOA application to Benefits

Administration, 10550 North Torrey Pines Rd., maildrop SP211, La Jolla, CA 92037.

Effective: 01/01/2017

Leave Of Absence Application Page 4