Family And Medical Leave Act Of 1993 Application Form - Metropolitan School District Of Wayne Township Page 6
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9LOA 1
SELECTION OF OPTIONS DURING LEAVE
In order for the Personnel and Business Offices to know your intentions concerning certain benefits
during your leave, please indicate below your choice of options and return the original and first copy
to the Personnel Office.
1.
Do you wish to continue your group life insurance?
Yes
No
2.
Do you wish to continue your health insurance?
Yes
No
3.
Do you wish to continue your dental insurance?
Yes
No
4.
Do you have a spouse employed by the MSD of Wayne?
Yes
No
(If so, your decision may affect his/her deduction for
health insurance and/or dental insurance.)
5.
Are you aware that sick and income protection plan
Yes
No
days must be used in conjunction with FMLA leave?
Date __________________
Signature _____________________________________
School _______________________________________
Grade/Subject _________________________________
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