LOA/FMLA REQUEST FORM
1. First Name
*
2. Last Name
*
3. Email
*
4. Phone Number
*
5. What type of leave are you requesting?
*
FMLA
LOA
Not Sure
6. Have you taken LOA/FMLA in the past twelve months?
*
Yes
No
Not Sure
7. Reason for requesting LOA/FMLA
*
Own personal medical reason
Care for a family member
Care for a newborn/placed child
Military
Other reason
9. If you chose other reason, please explain:
8. Your family member is your: (Spouse, child, parent)
10. Date of Hire
11. Requested start date:
*
12. Anticipated return date:
*
13. Do you participate in any of the insurance plans offered by Central State?
Yes
No
Unsure
15. Have you reviewed the Central State Policy for FMLA/LOA?
*
Yes
No
14. Which insurance(s) do you participate in?
Medical
Dental
Vision
Other
16. Amount of Vacation and/or Sick and Personal available:
Signature
*
By entering your name you agree that all of the information you entered is correct.
Today's Date:
*
Website
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