Archdiocese Of Los Angeles Family And Medical Leave Forms Page 12
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13Rights and Responsibilities Notice for Taking FMLA Leave (Continued)
Form B – Page 2
o Military Caregiver Leave: You may take up to 26 weeks unpaid leave, in a single 12
month period to care for a covered servicemember with a serious illness or injury.
Pregnancy Disability Leave: You may take up to 18 weeks leave per pregnancy
o
for pregnancy related conditions. In addition to pregnancy disability leave, you
may take up to 12 weeks of Family Care Leave.
•
You will be required to provide updated doctor’s notes or other appropriate certifications as needed
and to let your supervisor know of any changes anticipated in your leave status.
•
Your group insurance coverage will continue at your regular premium cost (employee portion) for a
period of four months, but you must make arrangement with the appropriate administrator at your
location to make your premium payments.
•
Should you fail to return after the end of the leave for a reason other than the continuation, recurrence
or onset of a serious health condition which would entitle you to FMLA leave or other circumstances
beyond your control, you may be liable for unpaid portions of insurance premiums.
•
While FMLA is unpaid leave, you may use available sick or vacation pay, where applicable, during
your FMLA leave, but this paid time off will counted as FMLA leave. Please refer to the sick and
vacation policy for your parish, school or ACC/Cemeteries for details.
•
Employees who have elected voluntary disability insurance coverage, may choose to apply for their
disability benefit if they are taking a leave of absence for their own illness.
•
Employees receiving disability payments cannot simultaneously receive sick or vacation pay.
•
You must be reinstated to the same or an equivalent job with the same pay, benefits and terms and
conditions of employment upon your return, provided you return within the 4 month (16 weeks)
maximum allowed for a leave of absence; or within the 26 weeks maximum allowed for Military
Caregiver leave.
Eligibility Authorized by: ________________________ Title: _________________________________
Location: _____________________________________ Date: _________________________________
Revised 2013
12
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business