LOA
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LOA
Other Than Family and Medical Leave
Application for Continuation of Group Insurance
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Before completing, please read document titled
"LOA: Continuation of Group Coverage While on Leave of Absence (LOA)
Other Than Family and Medical Leave" and LOA Rates
Employee’s Name: _______________________________________________
Address: _______________________________________________________
_______________________________________________________
Telephone Number: ______________________________________________
Social Security Number: __________________________________________
Campus: _______________________________________________________
Anticipated leave period: From ___________ To ___________
_______ Health Insurance
_______ Dental, Vision, Life
All benefits may be continued or just health insurance. If health insurance is not continued, dental, life, and vision care may be continued only as a package.
Signature: ____________________________ Date: __________________
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