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Click ‘Get Form’ to open the Sick Leave Disability Extension Form Checklist: F in the editor.
In Part 1, Employee Section, fill out your personal contact information. Ensure all fields are legible and complete. Check the box indicating if this is an address change.
Provide dates of illness, injury, or disability in Section 1-B. Make sure the Last Day Worked and First Date Absent match the Employer's records.
In Section 1-C, confirm that the illness or injury is your own by checking 'Yes'. If applicable, provide details about any related claims.
Sign and date in Section 1-D to certify your request for sick leave or disability extension.
Once completed, proceed to Part 2 for Employer Section where your employer will fill out their required information and sign.
Finally, ensure that Part 3 is completed by your physician if necessary. This includes their signature and date after your appointment.
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Extended Illness Bank (EIB) Summary Definition: An employee benefit that lets employees save up and use extra paid sick leave during an extended illness or severe injury.
What does EIB mean on my paycheck?
Extended illness or injury means a period of at least 3 or more weeks of illness or injury which is verified by a licensed health care practitioner to a maximum of 6 consecutive months.
What is extended illness leave?
Extended sick leave is a type of leave that allows employees to take an extended period off from work due to a serious illness or injury. This leave is typically longer than standard sick leave and may be necessary for recovery from major surgeries, chronic illnesses, or other significant health conditions.
What does extended illness mean?
PTO is used for the first two (2) eight (8)-hour days and EIB is used for the third (3rd) eight (8)-hour day.
How do I ask for disability extension?
If You Need to Extend Your DI Period You will receive a Physician/Practitioners Supplementary Certificate (DE 2525XX) with your final payment. Have your physician/practitioner complete and submit this form to find out if you are eligible for an extension. Your physician/practitioner can find your claim in SDI Online.
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You have a right under the FMLA to take unpaid, job-protected FMLA leave in a 12-month period for certain family and medical reasons, including up to 12 weeks
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