[Town of Wellesley] Leave of Absence Request Form

Section 1 of 1 in this document

Leave of Absence Request Form

Phone Number

Department/Division

Supervisor:

My supervisor is aware of my need for a leave of absence

I certify that I will speak to my supervisor as soon as possible about this request

(Estimated) Start Date of Leave

(Estimated) End Date of Leave:

Are you requesting intermittent leave?

Yes

Please explain your requested intermittent leave schedule

Are you requesting a reduced work schedule?

Yes

Please explain your requested reduced work schedule

Additional info you would like to share:

I elect to use the following and available paid time off:

Vacation Time

Sick Time

Personal Time

You are required to use your available paid time off to be paid while on a protected leave.

Policies remain in effect for all types of paid time off used, even on a protected leave (please see your union contract or the town's personnel policies).

You are responsible for requesting additional sick time if that option is available to you (please see your union contract or the town's personnel policies).

Insurance Disclosure Agreement

I understand that The Town of Wellesley will continue to deduct premiums for my benefits from my paychecks while on paid leave.

If unpaid while on a protected leave, I will receive a bill to pay each month, until I begin receiving paychecks again. Failure to pay within 30 days will result in the termination of my benefits.

Unpaid leave after a protected leave has ended will result in the termination of all benefits, except for medical insurance billed at the full premium.

I certify that I have read the above Insurance Disclosure Agreement.

Further paperwork may be sent to you to determine if your leave falls under one of the protected leave types. The paperwork must be completed and returned in a timely manner or your leave may be denied. The town has the right to designate your leave as a protected leave based on the information we currently have.

Please see the town's policies for more information.

Family Medical Leave (FMLA)
MA Parental Leave (MPLA)
Small Necessities Leave (SNLA)
Domestic Violence Law (DVLA)

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