Wku Request For Leave And Notice Of Eligibility And Rights & Responsibilities (Family And Medical Leave Act) Page 3

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cancelled, provided we notify you in writing at least 15 days before the date that your health
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.
While on FMLA leave you may be required to furnish us with periodic reports of your status and
intent to return to work every 30 days. If the circumstances of your leave change and you are able to
return to work earlier than the date indicated on the reverse side of this form, you will be required to
provide a release to return to work from your medical provider indicating the date of return.
If your leave does qualify as FMLA leave you will have the following rights while on FMLA leave:
The 12-month period measured forward from the date an employee’s first FMLA leave begins.
An employee is entitled to 12 weeks of leave during the year beginning on the first date FMLA
leave is taken; the next 12-month period would begin the first time FLMA leave is taken after
completion of any previous 12-month period.
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 is measured forward from the date of your first FMLA leave usage. This single 12-month
period commenced on: _________________________________________.
Your health benefits must be maintained during any period of unpaid leave under the same
conditions as if you continued to work.
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 you do not return
to work following FMLA leave for a reason other than:
 the continuation, recurrence, or onset of a serious health condition which would entitle
you to FMLA leave;
 the continuation, recurrence, or onset of a covered service member’s serious injury or
illness which would entitle you to FMLA leave; or
 other circumstances beyond your control, you may be required to reimburse us for our
share of health insurance premiums paid on your behalf during your 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.
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