Work & Well, Inc. - Medical Leave Request

Medical Leave Request Case Submission

Employee Information
All fields in this section are required.
First Name

Last Name

Social Security Number:

Home Address

City

State

Zip

Home Phone Number
(000)000-0000

Work Phone Number
(000)000-0000

Date of Birth
mm/dd/yy

Date of Hire
mm/dd/yy

Department	Job Title
Hours Worked per Week	Weekly Wage
Supervisor Name	Supervisor Email
First Day Out (mm/dd/yy)	Leave Start Date (mm/dd/yy)
FMLA Eligible?	FMLA Used in last 12 months:
State Disability Benefits?	LTD Eligible?
Employer Information All fields in this section are required
Employer	Employer Location
Submitted By	Date Submited (mm/dd/yy)
Submitter Email
Other Information
Estimated Return to Work Date (mm/dd/yy) Reason for Absence/Leave Indicate reason if "Other" is Selected STD Eligible Amount of STD eligible time Medical Insurance Eligible Wage Supplement Special Instructions

Work & Well, Inc. 2006