Form Wh-381 - Notice Of Eligibility And Rights & Responsibilities Page 2
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2If your leave does qualify as FMLA leave you will have the following responsibilities while on FMLA (only checked blanks apply):
Contact
at
to make arrangements
to continue to make your share of the premium payments on your health insurance to maintain benefits while you are on leave. You
have a 30-day grace period in which to make premium payments. If payment is not made timely, your group health insurance may be
cancelled, provided we notify you in writing at least 15 days before the date that your health insurance coverage will lapse, or, at our
option, we may pay your share of the premiums during FMLA leave, and recover these payments from you upon your return to work.
You will be required to use your available paid
sick,
vacation, and/or
other leave during your FMLA absence. This
means that you will receive your paid leave and the leave will also be considered protected FMLA leave and counted against your
FMLA leave entitlement.
While on leave you will be required to furnish us with periodic reports of your status and intent to return to work.
If the circumstances of your leave change, and you are able to return to work earlier than the date indicated on the first page , you
will be required to notify us at least two workdays prior to the date you intend to report for work.
If your leave does qualify as FMLA leave you will have the following rights while on FMLA leave:
1) You have a right under the FMLA for up to 12 weeks of unpaid leave in a 12-month period calculated as:
a "rolling" 12-month period measured backward from the date of any FMLA leave usage.
2) You have a right under the FMLA for up to 26 weeks of unpaid leave in a single 12-month period to care for a covered service
member with a serious injury or illness. This single 12- month period commenced on
.
3) Your health benefits must be maintained during any period of unpaid leave under the same conditions as if you continued work.
4) You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on
your return from FMLA protected leave. (If your leave extends beyond the end of your FMLA entitlement, you do not have return
rights under FMLA.)
5) If you do not return to work following FMLA 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;
3) other circumstances beyond your control,
you may be required to reimburse us for your share of health insurance premiums paid on your behalf during your FMLA leave.
If we have not informed you above that you must use accrued paid leave while taking your unpaid FMLA leave entitlement, you
sick,
vacation, and/or
other leave run concurrently with your unpaid leave entitlement,
have the right to have
provided you meet any applicable requirements for taking paid leave, you remain entitled to take unpaid FMLA leave.
Once we obtain the information from you as specified above, we will inform you, within 5 business days whether your leave will be
designated as FMLA leave and count towards your FMLA leave entitlement. If you have any questions, please do not hesitate to
contact:
at
Revised: August 2017
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