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Leave Request Form

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yeongmichael808
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16 views

Leave Request Form

Uploaded by

yeongmichael808
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Leave Request Form

Employee to Complete
Employee Name Employee Number

Address

Department Position

Supervisor/Manager

Status (select one)  Full-time  Part-time Date of Hire / /

I hereby request a leave of absence effective on / / (date you are requesting leave to commence).

I expect to return to work on


/ /

Reason for Requested Leave


Refer to your employee handbook for company leave policies. For questions regarding your company’s leave policies,
consult with your Human Resources department.
 Medical Leave
 Non-occupational Illness, Injury, or Pregnancy-related Disability

 Non -Medical Leave


Reason

Employee Signature Date / /

Employer to Complete
 Leave Approved

 Leave Denied
Reason

Leave is  Paid  Unpaid (select one)

Employee  is  is not required to exhaust all accrued  Vacation  Personal Time  PTO  Sick Days in accordance
with company policy and where permitted by state/ national law, before taking leave.
To the extent allowed by the insurance contract, we will continue to provide  medical insurance,
coverage during an authorized leave of absence, up to a maximum of months or for the
length required by applicable national leave laws. During this time you will be responsible for paying (your portion of) the
monthly premium(s). Your cost will be INR a month.
We will make reasonable efforts to return you to the same or similar job you held prior to the leave of absence, subject to
our staffing and business requirements. Please also refer to the applicable leave policy(ies) in your employee handbook
for additional information regarding reinstatement.

Supervisor/Manager Signature Date / /

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