FMLA Continuation Of Benefits Form

Complete a Benefit Continuation during Unpaid Leave form included with your first monthly invoice to ensure continuation of desiredbenefits and return the form to the Office of HumanResources with your first payment. Employer-paid benefits such as Group Term Life Insurance (GTLI) and Long-Term Disability (LTD) will automatically continue to

Benefits Continuation Tracking Once PAF received by Employee Records, they will update EV5 Employee Benefits and Wellness Division will administer the benefits accordingly as reflected by the employees status in EV5 • 4 unpaid pay periods under approved Non-FMLA status • The duration of the approved FMLA period while in unpaid status

PROTECTIONS DURING FMLA LEAVE . Group Health Insurance Benefits If an employee is provided group health insurance, the employee is entitled to the continuation of the group health insurance coverage during FMLA leave on the same terms as if he or she had continued to work. If family member coverage is provided to an employee, family member coverage must be …

Please refer to your “Continuation of Benefits During Leave of Absence (LOA) Form” for a list of the specific benefits, coverage level, and premium amounts you are currently enrolled (please see your Benefits Representative for this form) To be completed by Employee or authorized agent on Employee’s behalf: Employee Full Name: Personnel #:Home …

Family and Medical Leave Act (FMLA) Any employee (including part-time and temporary) of the University System of Georgia, who has: been employed by the University System of Georgia for at least twelve months total (not necessarily the last twelve months), and. worked at least 1,250 hours during the 12-month period immediately preceding the leave.

The FMLA Benefits Election Form is completed by the employee to indicate the benefit coverage the employee will continue, and contains information regarding the amount of the monthly payment for the benefit continuation. An employee can decline the benefit continuation provided by the FMLA during an unpaid leave of absence. That option is made available on the …

BENEFITS CONTINUATION LETTER [Date] [Employee Name] [Street Address] [City, State Zip] RE: BENEFITS CONTINUATION Dear [Employee Name]: As previously discussed, the [Parish/School/Diocese] has approved your request for a [Medical / Family or Pregnancy Disability] leave of absence. For the duration of this leave, the