Date:
[pic]
To: Central Benefits Office - Campus Human Resources
10920 Wilshire Blvd. Suite # 200
Phone: 310-794-0830
Fax: 310-794-0835, or
Email: @chr.ucla.edu
From: /
Re: Unpaid Leave of Absence Notice
Sections 1 to 5 of this Notice must be completed and immediately sent to the Central Benefits Office whenever an employee goes on an UNPAID leave of absence. Once received, the Central Benefits Office will send a leave packet. UCPath will send a letter with instructions about how and where to make direct payment of insurance premiums for any benefit plans an employee wishes to continue during all unpaid leaves of absence.
|Section 1 - Personal Information |
|Employee Name: |Employee ID #: |
|Home Department Name: |Home Department #: |
|Employee’s home address: |Employee’s phone #: |
|Employee’s personal email address: |
|Is employee normally scheduled to work a full 12 months each year? yes |Before this leave of absence, was employee working: |
|no |full-time part-time |
|If no, give periods of employment: | |
| |If part-time, was the reduction due to disability? |
|From to |yes no |
|Section 2 – Indicate Type of Leave (this list is not all inclusive) |
| |Attach Copy of: |
|Check One | |FMLA Letter |Job Description |
| |Employee Disability Unpaid Leave |Yes |Yes-Required |
| |Pregnancy Disability Unpaid Leave |Yes |Yes-Required |
| |Work Incurred Injury - Workers’ Compensation |Yes |Yes-Required |
| |Last Day of 80% Extended Sick Leave: | | |
| |Furlough |No |No |
| |Temporary Layoff |No |No |
| |Personal Leave |No |No |
| |Professional Development Leave (faculty only) |No |No |
| |Military Leave |No |No |
| |Postdoc Unpaid Leave |No |No |
| |Other Leave without pay (indicate type) | | |
| |Benefits Bridge – Non-Senate Faculty Only – Unit 18 |Re-employment Commitment Letter |
| | | |
Leave of Absence without pay Notice – Page 2
|Section 3 – Leave of Absence Dates |
| | |Date: (month/day/year) |
|1. |Last Day Actively at Work: | |
| |Number of hours worked: | |
|2. |Did employee receive ANY pay AFTER last day worked (#1 above)? yes* | |
| |no | |
| | | |
| |*If yes, indicate type and dates here: | |
| |Sick |From thru |
| |Vacation |From thru |
| |Comp Time |From thru |
|3. |Last Day on Pay Status: | |
|4. |Unpaid Leave of Absence Begin Date | |
|5. |Anticipated Return to Work/Pay-Status Date | |
|6. |Separation Date, if applicable | |
|Section 4 – FMLA Information |
|1. |Is any portion of this leave an approved FMLA? | yes no |
|2. |If yes, provide FMLA dates for this leave of absence: |First day of FMLA: |
| | |First day of Unpaid FMLA: |
| | |(this date will be equal to or later than Section 3.4 above) |
| | |Last day of FMLA: |
|Section 5 – Certification & Authorization |
|I certify this leave has been approved and recorded on-line in the PSFT System on this date: ___________ |
|Comments: |
| |
| |
|Authorized Initiator/Approver: |Department Name: |
|Campus phone #: |Department Mail Code: |
|Date: |Department Fax #: |
-----------------------
Campus Human Resources
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- e mail k12claims
- crf funds 2020 forms for covid 19
- change of name address form active employees
- early intervention central billing office
- welcome to middle georgia family health
- what everyone needs to know about social security
- unemployment benefit claims serlf service for employers
- home vnacj community health center
- employee benefits summary governors state university
- notice of disputed issue s and refusal to pay benefits
Related searches
- stock price by date lookup
- year to date market performance 2019
- maturity date calculator
- calculate maturity date of loan
- cd maturity date calculator
- date to date time calculator
- subtract today s date from another date excel
- date to date duration calculator
- date from a date calculator
- calendar date to date calculator
- from date to date calculator
- character date to numeric date sas