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FORM E - Employee Request for Leave of Absence or Temporary Disability NOTICE OF LEAVE OF ABSENCE FOR TEMPORARY DISABILITY INDEMNITY PAYMENT(FORM 29) GENERAL INFORMATION The followina steps must have occurred Prior to processing your Form 29 request. 1. Report your injury/illness to a Supervisor/Manager. 2 Complete and submit a DWC1-"Employee's Claim for Workers Compensation Benefits"form. 3. Complete and submit a"Request for Leave of Absence"form. 4. Provide medical documentation for the period of leave and any extensions. Your department will complete a 5020"Employers Report of Occupational Injury/Illness"form based on information provided on the DWC1 form. All forms will then be forwarded to the Human Resources,Risk Management Division. Workers compensation indemnity payments will begin when your claim is approved by San Joaquin County's Third Party Administrator. Effective 1/112008.Employees will have the following options. Please read carefulh. When an employee files a claim for workers'compensation,the Third Party Administrator(TPA)will have a period of time in which to accept,deny or delay a claim. By policy and practice,Workers'Compensation Leave runs concurrently with Family Medical Leave Act (FMLA),which provides 12,Aeeks of medical leave benefits for an injury/illness for eligible employees. The employee will have the following options to use leave accruals during this"determination period"and following the approval of the claim 80 hours Employee may elect to use 80 hours(or regular work schedule)of leave accruals per pay period,which will provide a regular paycheck and continue employee and dependent health insurance coverage. If the workers compensation claim is approved,employee will receive a partial reimbursement of leave accruals based on the indemnity payment determined by the TPA. 41 hours Employee may elect to use 41 hours of leave accruals per pay period,which will provide a partial paycheck and continue employee and dependent health insurance coverage. If the workers compensation claim is approved,employee will receive a partial reimbursement of leave accruals and a partial amount of the indemnity payment determined by the TPA. 0 hours As a Workers Compensation applicant,you also have the option of using zero hours. If your workers compensation claim is denied, this may impact your seniority hours Eligible for FMLA If eligible,health insurance coverage for employee will continue for up to 12 weeks.You must make arrangements through the Benefits Office to pay your share of health insurance premium to maintain your current health insurance coverage unless you have sufficient paid leave accruals to apply toward your portion of the premium. To continue dependent health insurance coverage,employee should contact Human Resources Benefits Section for employee's portion of premium amount. If the employee elects this option they will be placed on an FMLA-Leave of Absence without pay. Not Eligible for FMLA Employee and dependent health insurance coverage will terminate. To continue health insurance coverage, employee should contact Human Resources Benefits Section for information on over-the-counter payment. If the employee elects this option they will be placed on a Medical Leave of Absence without pay. If the workers compensation claim is approved,employee will receive a temporary disability indemnity payment for the period and amount determined by the TPA. At that time,employee's health insurance coverage will be reinstated and continuation of dependent health insurance coverage will require an over-the-counter payment to the Human Resources Benefits Section. Employee's leave status will be changed to a Workers'Compensation Leave,which will also adjust seniority hours and leave accruals approved by the TPA. Retirement Contributions Contributions towards retirement are based on hours on payroll per pay period. If using less than 80 hours(or regular work schedule) of leave accruals per pay period,contact the San Joaquin County Employee's Retirement Association for information regarding the effect on retirement service credit. I certify that I have read and understand the above information. Employee Signature Date: Print Employee Name: EE ID# Human Resources Form 29(09/2014) San Joaquin County Department of Public Works County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 29