This form is an application for Family and Medical Leave. It is to be filled out by an employee who is requesting a leave of absence.
Michigan Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word
Instant download
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How to fill out Employee Application For FMLA?
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FAQ
Although FMLA leave is unpaid, employees may be allowed (or required) to use their accrued paid leave during FMLA leave. When an employee's FMLA leave ends, the employee is entitled to be reinstated to the same or an equivalent position, with a few exceptions.
Doctors aren't the only health care providers who may certify FMLA leave. Podiatrists, dentists, clinical psychologists, optometrists and chiropractors can all certify leave, as can nurse practitioners, nurse-midwives, clinical social workers and physician assistants.
Although FMLA leave is unpaid, employees may be allowed (or required) to use their accrued paid leave during FMLA leave. When an employee's FMLA leave ends, the employee is entitled to be reinstated to the same or an equivalent position, with a few exceptions.
To apply for a medical leave of absence:Submit your application: Online, or. Print, complete and fax an Application for Leave of Absence.Have your treating physician complete one of the following: FMLA Certification of a Serious Health Condition, or. Non-FMLA Medical Certification200b
How to File a Paid Family Leave (PFL) Claim by MailVisit Online Forms and Publications and order a form online. A form will be mailed to you.Obtain the form from your physician/practitioner or employer.Visit an SDI Office.Call 1-877-238-4373. California Relay Service (711) Provide the PFL number (1-877-238-4373)16-Feb-2022
To apply for FMLA, the employee must take an FMLA Medical Certification Form to their health care provider. This form ensures that the employee's or family member's applicable health condition is valid. After receiving the form, the employee must return it within 15 calendar days.
To be eligible for FMLA, you must have 12 months of employment with the State of Michigan (does not need to be consecutive) and you must have physically worked 1,250 hours within the previous 12 months. For questions on FMLA eligibility, contact the Disability Management Unit (DMU) by phone at 877-443-6362.
EligibilityHave worked for your employer for at least 12 months; and.Have worked for your employer for at least 1,250 hours in the 12 months before you are taking leave; and.Work at a location where your employer has at least 50 employees within 75 miles of your worksite.
In order to be eligible to take leave under the FMLA, an employee must (1) work for a covered employer, (2) work 1,250 hours during the 12 months prior to the start of leave, (3) work at a location where 50 or more employees work at that location or within 75 miles of it, and (4) have worked for the employer for 12