Employer Information

FMLAssistSM Leave Intake Form

Please complete this form and submit to [email protected]

This section must be completed in it’s entirety or the Employer Information employee’s request for leave may be delayed or denied Employer Name Address: City: State: Zip: 00000-0000 Contact: Phone Number: 000-000-0000 ext. Company’s 12-month tracking for FMLA Entitlement: Select Tracking Method

Employee Information This section must be completed in it’s entirety or the employee’s request for leave may be delayed or denied

Name: SSN or ID: 000-00-0000 Home Address: Work State: City: State: Zip: 00000-0000 Phone Number: 000-000-0000 This section must be completed in it’s entirety or the Leave Information employee’s request for leave may be delayed or denied

Please select a reason for this leave request: Select Leave Type Does the employer enforce the 12 week rule for spousal limitation of time? Yes No Does the spouse work for the same employer? Yes (spouses SSN or ID# 000-00-0000) No Complete the applicable section based on the employee’s reason for leave

Family Member Serious Health Condition Care of Newborn

Covered Family Member: Select Family Member Child’s DOB: If Other, define relationship: If Child, provide Child’s DOB: Care of Newly Adopted Child Care of Child Newly Placed for Foster Care

Date Child was placed for adoption: Date child was placed for foster care:

Servicemember Caregiver Leave

Covered Servicemember: Select Relationship If Other, define relationship: If Child, provide Child’s DOB:

1 of 3 This section must be completed in it’s entirety or the Dates & Frequency employee’s request for leave may be delayed or denied First Date Off Work: Is Employee eligible for FMLA as of the first date off work? Yes No

Date Employee reported absence: Date Rights Package was mailed: Was notice of eligibility provided to the employee verbally? Yes No If yes, date the employee was notified: Was notice of eligibility provided to the employee in writing? Yes No If yes, date the employee was notified: Date Health Care Provider Certification (HCPC) or other certification information due: Date HCPC or other certification information was received: What type of leave frequency is being requested? Select Frequency

If the requested leave frequency is intermittent and the leave is for child bonding, complete the following: Is intermittent child bonding leave allowed? Yes No If yes, have the absence date(s), as requested by the Employee, been approved by the Employee’s supervisor or manager? Yes No

Foreseeable Leave An Employee must provide at least 30 days advance notice before FMLA leave is to begin if the need for the leave is foreseeable based on an expected birth, placement for adoption or foster care, planned medical treatment for a serious health condition of the employee or of a family member, or the planned medical treatment for a serious injury or illness of a covered servicemember. Is the Employee’s need for leave foreseeable? Yes No If no, complete the Unforseeable Leave section below. If yes, did the Employee provide 30 days in advance notice? Yes No If no, did the Employee why provide notice as soon as practicable? Yes No If no, please provide the Employee’s reason for not reporting the leave in a timely manner:

Unforeseeable Leave When the approximate timing of the need for leave is not foreseeable, an Employee must provide notice as soon as practicable under the facts and circumstances of their particular leave request. Did the Employee report the leave within your normal timeline? Yes No If no, did the Employee provide notice as soon as practicable? Yes No If no, please provide the Employee’s reason for not reporting the leave in a timely manner:

Late HCPC or Other Certification Documentation This section must be completed if the Employee provided the requested HCPC or other certification information after the date in which it was due Please provide the Employee’s reason for not providing the HCPC or other certification documentation I a timely manner:

2 of 3 Previous Leave Information

Is this a request for reconsideration of an adverse leave decision? Yes No Is this a request for re-certification? Yes No Has the employee previously used FMLA time? Yes No

Please use the appropriate checklist below to verify that all information is included in the claim submission. Once the claim is ready for submission, please send all documents to MetLife FMLAssist at [email protected] or fax to 855-880-3132. For questions on how to complete this form, please contact MetLife FMLAssist at 855-517-8275.

Initial Certification Claim Submission Checklist

HCPC or Other Certification Documentation Time Tracking Spreadsheet Work and Holiday Schedule Spreadsheet Completed Leave Intake Form

Re-certification Information and Checklist

Did MetLife make the initial decision? Yes No If yes, please provide the initial leave number:

HCPC or Other Certification Documentation Time Tracking Spreadsheet Work and Holiday Schedule Spreadsheet Previous Designation Letters Completed Leave Intake Form

Reconsideration Checklist

HCPC or Other Certification Documentation Time Tracking Spreadsheet Work and Holiday Schedule Spreadsheet Previous Designation Letters Completed Leave Intake Form

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