Ffcra leave request form - M3 Insurance 2026

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The document is an employee request form for paid leave of absence under the Families First Coronavirus Response Act (FFCRA). It outlines the reasons for requesting leave related to COVID-19, including quarantine orders, self-quarantine advice from healthcare providers, caring for affected individuals, and childcare issues due to school closures. Employees can request continuous or intermittent leave and indicate any paid leave they wish to utilize during their absence. The form also includes sections for additional information and requires employee signatures to confirm the need for leave.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name, date, job title, and department at the top of the form.
In section A, specify the dates for your requested paid leave under the Emergency Paid Sick Leave Act. Indicate the reason for your leave by checking the appropriate box and providing any required details, such as names of health care providers or governmental entities.
If applicable, choose between continuous or intermittent leave based on your situation in section A.
Proceed to section B to request approval for a paid leave under the Emergency Family and Medical Leave Expansion Act. Again, fill in the dates and provide necessary information about your child(ren) if relevant.
In section C, describe any intermittent leave needs and provide specific days and times you will require this arrangement.
Finally, sign and date the form at the bottom to confirm your requests and understanding of insurance coverage arrangements.

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