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.
Palm Beach Florida Employee Application for FMLA
State:
Multi-State
County:
Palm Beach
Control #:
US-AHI-200
Format:
Word
Instant download
Description
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How to fill out Employee Application For FMLA?
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FAQ
The FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave.
You do not have to tell your employer your diagnosis, but you do need to provide information indicating that your leave is due to an FMLA-protected condition (for example, stating that you have been to the doctor and have been given antibiotics and told to stay home for four days).
Applying for FMLA The employee's health care provider must complete a certification form that validates the employee's serious health condition or that of an immediate family member. The employee must provide this certification to the employer within 15 calendar days of receiving it.
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
It is against the law for a covered employer to deny an eligible employee's proper request for FMLA leave. Your employer can't require you to perform any work while you are on approved FMLA leave.
Employees are eligible for FMLA leave if: they have worked for the company for at least a year. they worked at least 1,250 hours during the previous year, and. they work at a location with at least 50 employees within a 75-mile radius.
FMLA - Serious Health Condition Alzheimers disease; chronic back conditions; cancer; diabetes; nervous disorders; severe depression; pregnancy or its complications, including severe morning sickness and prenatal care; treatment for substance abuse, multiple sclerosis;
Dear (Supervisor / HR Manager): Please be advised that I hereby request an FMLA leave for a period of (number of weeks) in connection with my serious health condition. The leave is to start on (date). Attached is my medical note reflecting the need for FMLA leave.
Dear (Supervisor / HR Manager): Please be advised that I hereby request an FMLA leave for a period of (number of weeks) in connection with my serious health condition. The leave is to start on (date). Attached is my medical note reflecting the need for FMLA leave.
By Lisa Guerin, J.D. Like employers throughout the country, Florida employers must comply with the federal Family and Medical Leave Act (FMLA), which allows eligible employees to take unpaid leave, with the right to reinstatement, for certain reasons.