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How to use or fill out EMPLOYEE: COMPLETE THE FOLLOWING (top of this page only) with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by entering your name in the 'Employee’s Name' field. Ensure that you print clearly for easy readability.
- Next, provide your Employee Number and Health Insurance Provider along with your Member Number.
- Fill in your Work Location and Job Title accurately to reflect your current position.
- Indicate whether the health condition is claimed as 'Serious' under FMLA by selecting 'yes' or 'no'. Specify if the leave is for yourself or a family member.
- If applicable, describe the care you will provide for a family member, including an estimate of the care period and any intermittent work schedule.
- Sign and date the authorization statement confirming that you agree to its terms. If applicable, include the family member's name and relationship.
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