Leave of Absence (LOA) Request
CHECK ONE
□ Original Request □ Extension Request TO BE COMPLETED AND RETURNED TO THE FMLA/WORKER’S COMPENSATION MANAGER PRIOR TO LEAVE Employee Name: ___________________________________________________ Employee # ____________ Home Phone #:____________________________________Work Phone #:____________________________ Home Address:____________________________________________________________________________ (Including city, state, and zip code) Manager: _____________________________________________________________ Ext.:_______________ Location/Dept.:_______________________ Timekeeper: _________________________________________ Ext.;_________________________________

Reason for Leave of Absence: _____________________________________________________________________________________________ ___________________________________________________________________________________ _____________________________________________________________________________________________ ___________________________________________________________________________________ Was FMLA previously utilized? □ yes □ no EMPLOYEE SECTION: Information to Employee about Leave of Absence: *Employee’s signature is required on all leave requests* I have reviewed the Leave of Absence Policy and fully understand the policy and the process. □ yes □ no (Please check only one box) 1. I understand that my present position, schedule and work assignment are not guaranteed once I return from LOA. I have discussed this with my supervisor and expectations have been established. If my present position, schedule or assignment is not available at the end of my LOA, I understand that I must find/accept another suitable position in order to maintain my employment with MCG Health, Inc. If LOA is granted for health reasons, I must provide a full medical release from my physician, permitting me to fully perform the duties of my job, before I will be allowed to return to resume full job duties. (utilize Fitness for Duty form attached) Upon returning from LOA, my “next performance review date” will be adjusted to coincide with the period which I am on LOA. My date of hire, however, will not be changed. Accrued time will not continue to accumulate while I am on LOA.

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During the LOA, I may elect to maintain my benefits coverage at the current rate. I understand that I will receive a communication from Benefit Programs, Human Resources with payment due to MCG Health, Inc. If payment is not received within the required timeline, my insurance will be cancelled. I understand that if my benefits are canceled due to non-payment of premiums, I will be eligible to reapply for insurance upon my return from leave. The effective date of my new plans will be my first day