Leave Of Absence Packet (Page 2 of 3) in pdf

Leave Of Absence Packet Page 2

LEAVE OF ABSENCE PACKET

PRE-LEAVE CONFERENCE CHECK LIST

Please place your initials before each statement below indicating acknowledgement.

Unpaid Status

_______ I understand that when in unpaid status, my anniversary date will be advanced by

the amount of time that I am on leave.

_______ I understand that when in unpaid status, I will not be accruing vacation, sick or

administrative leave time and that the balances presently reflected on my record will be

adjusted to reflect my unpaid leave.

Benefits

_______ I understand that I am responsible for pre-payment of Health/Dental/Prescription co-

payments in the amount of $_______. I further understand that payments are to be paid by

the first of each month.

_______ I choose to have my payments deducted from my last check prior to my leave.

_______ I understand that if I choose to waive coverage, I must do so by the 5

of the month.

Failure to waive by the 5

of the month will result in charges for the following month.

Miscellaneous

_______ I understand that I must provide documentation of any extensions at least two (2)

weeks prior to my original leave end date.

_______ I understand that upon my return, I may purchase service credits for pension

purposes for the time that I was on leave of absence (CWA, IFTE).

_______ I understand that it is my responsibility to provide documentation to New Jersey

Disability and Family Leave Insurance when requested.

_______ I have received Disability form, FLI form and Benefit costs.

_____________________________________

________________________________

Employee Signature

Date

HR Rep Signature

Date

Rev 1/813

Leave Of Absence Packet Page 2