FCA Employee Application for Family & Medical Leave of Absence

(* Denotes Required Fields)

Employee Information
Name: *
Date: *
Address (Street, City, State, Zip Code): *
Program: *
Hire Date: *
Status: *	Full-Time Part-Time
Date Leave to Begin: *
Return to Work Date: *
Qualifying Reason for Leave: *	The birth of a child, or the placement of a child with you for adoption or foster care. A serious health condition that makes you unable to perform your job. A serious health condition affecting a family member for which you are needed to provide care. To serve as an organ or bone marrow donor. Qualifying exigency arising out of the covered active duty (for self or immediate family). Military caregiver leave for covered servicemember or covered veteran (immediate family and next of kin).
Expected Delivery / Placement Date (Please write N/A if not applicable): *
Please review the following statements and check the box if you understand
I understand that, if qualified, I have the right under the CT FMLA for up to twelve (12) weeks of leave in a twelve (12) month period for the reasons listed above. Under the Federal FMLA, if qualified, I have the right for up to twelve (12) weeks of leave in a twelve (12) month period. If the leave qualifies me for both Federal and CT FMLA, the leave may count against my entitlement under both laws and run concurrently. I understand that any previously taken qualified leaves may offset the balance of mu currently available unpaid time.: *	I understand
I understand that when the leave begins, I will be required to utilize your accrued Paid Time Off (PTO) concurrently while on FMLA leave. Connecticut FMLA allows employees to retain two (2) weeks of accrued unused Paid Time Off (PTO).: *	I understand
I understand that during the leave, my voluntary benefits (including health benefits) may be maintained during any period of FMLA leave (under the same conditions as if you were actively working at FCA). I understand that during my leave, I will be responsible for maintaining payment of the employee portion of insurance premiums (for my voluntary benefits).: *	I understand
It is anticipated that I will return to work upon completion of this leave of absence, on the date indicated above. It is understood that should I elect not to return to work at the end of this leave, or choose to not maintain mu full-time employment status, I will be charged the full COBRA amount for all health insurance coverage during any unpaid portion of FMLA leave. : *	I understand
I understand that further details on my FMLA rights and responsibilities will be provided to me in response to this leave of absence request form.: *	I understand
Employee Signature
Name and Employee Code: *