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Non-Medical Leave of Absence Checklist

Before Your Leave of Absence Begins:  Contact Liberty Mutual to file for job protection under FMLA – this must be done for ALL leave requests.  Call Liberty Mutual at (877) 201-3050

 Contact Your Manager  With your manager, fill out the Request for Leave of Absence Form and FAX a copy to the Benefits Department at (617) 632-9430.  If you wish to retain any Earned Time (ET) hours (if applicable), inform your manager and note this ET request on the Request for Leave of Absence Form (Section III).

 Suspend Elective Payroll Deductions  If you would like to suspend your elective payroll deductions, make your request at the beginning of your leave. For any parking or commuter pass deductions, please contact Commuter Services directly at (617) 667-3052 or by email at [email protected] before going on leave.

During Your Leave of Absence:  Follow up with Liberty Mutual regarding any required documentation they may need to approve your leave of absence. For any FMLA questions, please call (800) 283-0823.

 Call your manager at least once per month to keep in touch.

 If you anything changes while you are on leave, contact Liberty Mutual directly.

 If you are taking an Intermittent Leave, please be sure to report any FMLA time taken directly to Liberty Mutual. If you have questions on how to report your intermittent FMLA time used, please contact Liberty Mutual directly at (800) 283-0823.

Before Returning From Leave of Absence:  Contact your manager two (2) weeks prior to returning to work to coordinate your return and to ensure reinstatement.

On Your First Day Back from Continuous Leave:  Give your Manager your Return to Work Form and once completed, fax it to the Benefits Department at (617) 632-9430.

Questions:  Contact the Benefits Office  Phone (617) 632-9453  Fax (617) 632-9430  Email [email protected] Request for Leave of Absence Form Fax to the Benefits Department at (617) 632-9430 or 2-9430

A Leave of Absence is intended to grant an employee time away form his/her job for a specific purpose and for a usually specified, and often extended, length of time. In general, Earned Time (ET) is deducted from an employee’s remaining ET bank and, if appropriate, Extended Illness (EI) bank.

Section I: General Information

Employee Name: ______Employee Payroll ID: ______

Employee Mailing Address: ______

Employee Phone Number: ______Hours Per Week: ______Dept: ______

Manager’s Name: ______Manager’s Phone/Email: ______

Section II: Length & Type of Leave

Last day worked: ______Estimated return to work date: ______

I am requesting a leave of absence for the following reason:

( ) Paternity / Adoption ( ) Medical/family member: ______

(relationship) ( ) Military ( ) Medical Mission Leave

( ) Military/FMLA Qualifying Exigencies ( ) Military/FMLA Caregiver Leave

Is this an Intermittent Leave? ( ) NO ( ) YES (If YES, please skip Section III)

Section III: Earned Time

I would like to retain ______hours of Earned Time. (80 hours max for full time employees and pro-rated for part-time employees)

Section IV: Reinstatement Guidelines

Please read the following and sign below:

 I understand Beth Israel Deaconess Medical Center cannot guarantee my job will be available at the time I return to work. Efforts will be made to reinstate me in either the same or a comparable position. Reinstatement following Family & Medical Leaves will be made in accordance with the Family & Medical Leave Act of 1993.

 I understand I must provide the Benefits Office with a completed Return to Work form on my first day back from leave.

 I understand if circumstances change such that I will not return to work on date specified above, I agree to inform my manager/supervisor, Liberty Mutual (if applicable) and the Benefits Office immediately.

Employee’s Signature: ______Date: ______

Manager’s Signature: ______Date: ______Leaves of Absence - Promise to Pay Benefit Premiums

Employee Name: ______Employee Payroll ID ______

With regard to Beth Israel Deaconess Medical Center’s group health, dental, vision and life insurance plans (collectively, the “Plan”), the Medical Center continues to pay that share of the premium cost of your coverage and that of your eligible dependents (“Coverage”) that it pays for active employees (and their eligible dependents) while you are out of work on an authorized Leave of Absence, for any reason, for up to one year. However, you must continue to pay the employee share of the premium cost of your Coverage. While you are on a paid Leave of Absence, including pay through the Medical Center’s Earned Time (ET) and/or Extended Illness (EI) programs, you will continue to pay for the employee share of the premium cost of your Coverage through pre-tax payroll deductions. While you are on an unpaid Leave of Absence, you must pay for the employee share of the premium cost of your Coverage.

I hereby authorize:

BIDMC to deduct from my payroll check, immediately upon my return to work at the Medical Center from unpaid leave of absence, the employee share of the premium cost of Coverage of my group health, dental and vision benefits (which I understand accrues weekly during my leave of absence). I understand that if my first payroll check is insufficient to cover the full amount of premiums that I owe for Coverage during my unpaid leave of absence, deductions will be made from my subsequent payroll checks until the entire amount has been paid. Repayments will be allocated to the earliest period of Coverage for which payment has not yet been made. I understand that the deduction(s) from my payroll check will be made post-tax and that the amount of the deduction from each payroll check is subject to applicable state and federal minimum wage laws. I also understand that should my employment with the Medical Center end prior to my full payment of the amount owed, the entire amount still owed will be due immediately upon separation, and I agree to pay the amount owed no later than 7 days (30 days in the case of an FMLA leave of absence) after the due date. I further understand that if I fail to make timely payment of the full amount due, my coverage will be terminated retroactively to the first day of the month for which timely payment was not made, and the Plan may seek reimbursement of any benefits paid to my dependents or me during such time.

______Employee Signature Date BETH ISRAEL DEACONESS MEDICAL CENTER Your Benefits While On Continuous Leave Of Absence Medical, Dental, Vision, Prepaid Legal and Life Insurance for Spouse and Dependent If you are currently enrolled in medical, dental, vision, prepaid legal, and/or life insurance for spouse/dependent, your coverage(s) will continue provided you pay your share of the cost through payroll deduction during your leave or upon your return if you go into an unpaid leave status. Should your leave exceed the job protected period or your position is no longer being held, you will be invoiced for the balance as well as the remaining months of coverage. Payments are due upon receipt of invoice and failure to pay the balance due will result in termination of your coverage retroactive to your last payment. Life Insurance and Accidental Death and Dismemberment (AD&D) If you are currently enrolled in life and/or AD&D insurance program, coverage(s) will continue for 12 months if you are on family or medical leave, provided you pay your share of the cost (both FMLA and non-FMLA family/medical leaves). If you become totally disabled, your life insurance coverage may be extended beyond the normal twelve months period at no cost to you, by filing an application of waiver of premium. For more information on waiver of premium, please contact the Benefits Office. Short and Long Term Disability If you are enrolled, short and long- term disability coverage is extended to those who are on a maternity/medical leave of absence. If you are on another type of a leave, disability coverage will end as soon as the unpaid portion of your leave begins, and resume when you return to work. Earned Time/Extended Illness may be paid concurrent with any disability payment but the combination of ET/EI and disability payments cannot exceed 100% of your base pay during your period of disability. For more detailed information concerning your disability plan, please read the Disability Summary of Coverage or contact Liberty Mutual directly. Flexible Spending Accounts If you participate in a Flexible Spending Account, contributions will stop as soon as the unpaid portion of your leave begins, and resume when you return to work. Your weekly deduction amount will be recalculated to meet your annual pledge amount. You may submit claims to your account through March 31st of the following calendar year. Earned Time/ Extended Illness Accruals will continue while your leave is paid. You do not accrue Earned Time (ET) or Extended Illness (EI) while on an unpaid leave of absence. Accruals will resume if you return from an unpaid leave into a benefits eligible position. Pension All eligible employees with one year of service who work 1,000 hours or more in a calendar year earn credited service under the pension plan. If you are paid less than 1,000 hours (combination of wages and ET/EI) you will not receive pension credits for that calendar year. If you are concerned about the effect of a leave on your pension, please contact the Benefits Office. 401(k) and 403(b) Contributions stop when you are on an unpaid leave and resume when you return to work. If you would like to stop your contributions while on a paid leave, you need to contact Fidelity directly. Tuition Reimbursement Tuition reimbursement cannot be used or paid while you are on leave. Your eligibility is immediately reinstated upon return to a benefits eligible position. Parking/MBTA Pass If you have a subsidized parking space or payroll deduction for T Pass, you MUST contact Commuter Services in writing by fax @ 667-7693 or by email at [email protected] to arrange suspension of the deduction or you will be responsible for the cost while on leave. For MBTA passes, you have the option of either canceling or keeping the pass active while on leave. They cannot be placed on hold. If you wish to keep your pass active, no action is necessary; however, your deductions will be doubled upon return until payment is caught up. For parking, you must notify Commuter Services a few business days prior to going on leave (no earlier than one week). Your parking will be placed on hold and you can resume upon your return. If you have any questions, you may call Commuter Services at (617) 667-3052. Salary and Merit Review Dates Your salary will not change during the unpaid portion of your leave and your merit review date will be unchanged for 3 months of leave. If your leave is longer than 3 months, your merit review date will be adjusted in one-month increments for each additional month you are on leave. If you are a supervisor or manager, you will retain your merit review date and may receive a prorated merit increase if you have returned from leave during the preceding 12 months. Annual Enrollment If you are on leave during our annual open enrollment (OE), you will receive your OE information in the mail to your home address. Family Status Change If you experience a family status change while on leave, you may change your coverage level by completing a Change in Lifestyle Form available on the portal and through the Benefits Office. You must notify the Benefits Office of your change in lifestyle within 30 days. If you have additional questions, please contact the Benefits Office at (617) 632-9400. Return to Work Form

To be completed on the first day the employee returns to work from Continuous Leave

Fax to the Benefits Department at (617) 632-9430 or 2-9430

Employee Information

Name:

Payroll ID:

Department:

First Day Worked:

Manager Information

Name:

Telephone:

______Manager Signature Date

This completed form must be received on the employee’s first day back to work for your employee to be paid.

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