COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

NOTICE OF LEAVE OF ABSENCE FOR TEMPORARY DISABILITY INDEMNITY PAYMENT Name: Date: Home Address: Ci Zip Code: Department: I Division: Title: I EE M#: Home Telephone: Our records indicate that you may be eligible to receive Temporary Disability Indemnity payments as a result of an on-the-job injury or illness. The date of your injury or illness was and you have been off work since . Please read this form and fill in the information requested. Sign and return it to your department with a Request for Leave of Absence form. WORKERS' Workers'Compensation leave runs concurrently with Family Medical Leave Act(FNMA). Eligible COMPENS4770N employees are entitled to 12 weeks of FMLA. After the 12 weeks,if the employee is not released to return LEyVE to work full duty,workers compensation temporary disability will continue if eligible. Employee must complete a Request for Leave of Absence(RLOA)and Employee's Claim for Workers'Compensation Benefits(DWCI)forms with their department. WORKERS' Employee submitting a claim for Workers Compensation Temporary Disability Indemnity payments may COMPENS,4770N elect to use one of the following increments of leave accruals per pay period. The MOU requires sick BENEFIT PAYMENT leave accruals used first. If this is exhausted,employee may elect to use the following: OP77ON(See cover ❑ 80 hours(regular work schedule) ❑41 hours ❑0 hours(off payroll) page for additional ❑ I want to use accrued: ❑Sick ❑Vacation ❑Holiday❑ Compensatory information) ❑ I do not want to use any of the above and elect to receive a temporary disability indemnity payment when my claim is approved.(Mark 0 hours,off payroll above). HEALTH You must make arrangements through the Benefits Office to pay your share of health insurance premium to INSURANCE maintain your current health insurance coverage unless you have sufficient paid leave accruals to apply PREkgUgS toward your portion of the premium. Employee may continue dependents'health coverage during the time they are receiving temporary disability indemnity payments by paying the premiums in advance to the Human Resources,Benefits Division. Dependents health coverage will continue if you are using 41 hours or more of leave accruals. RETURNFROM The employee must present to their department a medical clearance from their physician to return to work. WORKERS' COWENS77ON r r When Temporary Disability Indemnity payments are discontinued and all leave accruals have been NOTICE exhausted,and the employee has not received a medical clearance from their physician to return to work, the employee shall apply for a leave of absence without pay. During leave of absence without pay the employee is responsible for health insurance premium payments. Contact the Human Resources,Benefits Division for more information on continuation of health insurance benefits. While on a leave of absence without pay,employee does not accumulate leave accruals. I certify that I have read the above information. Signature of Employee FOR DEPARTMENT USE ONLY Date Appointing Authority or Designated Representative FOR HUMAN RESOURCES USE Distribution: Original: HR/RiskManagement Claim#: Copy: Employee's Dept&Timekeeper Human Resources Form#29(Revised 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 30