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Get Benefits Continuation Election Form

Pplies) FMLA/Medical Military Worker s Comp Other: Reason for Requested Leave: Start Date (first day of leave): Last Date worked: Expected return to work date*: *You are responsible for contacting your supervisor and HR with changes in this date. 6. Short Term Disability (STD) / Long Term Disability (LTD): Eligible employees are covered by LTD after a 90 day elimination period. The benefit paid is 60% of the employee s base earnings. Employees are required to use accrued.

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ssa form 795 benefit continuation election statement rating
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