Circle One:Salary / Hourly

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2700 Judge Fran Jamieson WayInstructional / Admin / EAP / Support Viera, FL 32940-6699Run#

LEAVE OF ABSENCE REQUEST

Legal Name (Please print): SSN:

Home Address: City/State/Zip:

School/Department Name: School Dept #:

Job Title:Must match Board approved job description title

Hours worked per day:

PAID LEAVE TotalHours

TotalDays

Begin End(circle one)

*PayrollCode

Jury Duty/Court Service(Copy of Summons & Clerk of the Court verification for each day absent)

TO/AND JUR

Other Paid Sick Bank Union National Board TO/AND ***

Sick (In excess of 5 consecutive days) Self Family Illness/Death TO/AND SCK

Military (Reserve/National Emergency duty-attach orders) TO/AND MIL

Injury In the Line of Duty (10 days maximum PAID per fiscal yr)Receiving Workers' Compensation (WC)

TO/AND PIL

UNPAID LEAVEMilitary (Reserve/National Emergency duty-attach orders) TO/AND MLN

Personal Field Trip Court Other*2 year maximum

TO/AND PNP

Illness*Attach doctor's statement in excess of 5 consecutive days*Must exhaust all accumulated sick for Employee illness*Must not be used with FMLAReceiving Workers' Compensation (WC)

TO/AND NIL

orLOA

Family Medical (FMLA)***Medical Certification from doctor *FMLA eligibility form (Teachers exempt)Self Family Member Meets 1,250 hrs BPS Employee for 12 months

TO/ANDFML

Maternity/Adoption *Attach doctor's statement or adoption agreement*Requests must be made 5 calendar weeks before estimated delivery or adoption date

TO/AND LOA

Child Rearing *May ONLY follow an approved Maternity/Adoption leave TO/AND LOA

Professional Study TO/AND LOA

*Enter payroll code in the time exception until position has been ended

ACKNOWLEDGEMENTS FOR UNPAID LEAVES ~ All employees MUSTinitial below and sign form to complete this requestInitial I understand that I can use my accrued sick, personal or vacation time before I begin an unpaid leave of absence in accordance with Board policy. I

understand that the Board paid benefit on leaves of absence for WC and Extended Illness are only provided for a specific period of time and only for medical,vision and employee life. FMLA is a Board paid medical only benefit. I understand since I am not receiving a paycheck, that I must pay for my benefits tocontinue my coverage. (Please see chart on back of form.)

YES NOI wish to continue my current benefit elections by making proper payments to the Compensation & Benefits Department,otherwise they will be cancelled. (See Cost Estimator on the reverse side of this form)

MY SIGNATURE SIGNIFIES THAT I HAVE READ THE INFORMATION ON THE REVERSE SIDE OF THIS FORM, SPECIFICALLY MY RIGHTS UNDER THE

FAMILY MEDICAL LEAVE ACT (FMLA). I CERTIFY THAT THE INFORMATION SUBMITTED ON THIS REQUEST IS ACCURATE.

Signature of Employee Date

Principal/Admin/Supv Leave Approved ( ) Disapproved ( )

Human Resources Administrator Leave Approved ( ) Disapproved ( )

BLUE INK ONLY

BLUE INK ONLY

⇒LOA Original: Compensation & Benefits ⇒ Copies: Payroll/Employee/Department

_____________________

Cost Estimator for 2006 Gross Benefit Premiums for Employees on Unpaid LOA21 Pay 22 Pay 23 Pay 24 Pay 25 Pay 26 Pay

Medical Aetna & Health First Employee Only 12.38 11.82 11.31 10.84 10.40 10.00Medical Aetna & Health First Employee + Spouse 205.04 195.72 187.21 179.21 172.23 165.61Medical Aetna & Health First Employee + Children 110.44 105.42 100.84 96.64 92.77 89.20Medical Aetna & Health First Employee + Family 272.27 259.89 248.59 238.24 228.71 219.91Medical Aetna & Health First Joint Employee + Children 21.62 20.64 19.74 18.92 18.16 17.46Medical Cigna Basic Employee Only 0.00 0.00 0.00 0.00 0.00 0.00Medical Cigna Basic Employee + Spouse 73.62 70.27 67.22 64.42 61.84 59.46Medical Cigna Basic Employee + Children 52.77 50.37 48.18 46.17 44.32 42.62Medical Cigna Basic Employee + Family 196.03 187.12 178.99 171.53 164.67 158.34Medical Cigna Basic Joint Employee + Children 15.57 14.86 14.21 13.62 13.08 12.57Medical Cigna EPO Employee Only 24.72 23.60 22.57 21.63 20.76 19.97Medical Cigna EPO Employee + Spouse 230.43 219.95 210.39 201.63 193.56 186.12Medical Cigna EPO Employee + Children 124.15 118.51 113.36 108.64 104.29 100.28Medical Cigna EPO Employee + Family 313.41 299.16 286.15 274.23 263.26 253.14Medical Cigna EPO Joint Employee + Children 42.20 40.28 38.53 36.93 35.45 34.08Medical Cigna PPO Employee Only 124.83 119.16 113.98 109.23 104.86 100.83Medical Cigna PPO Employee + Spouse 422.44 403.24 385.71 369.64 354.85 341.20Medical Cigna PPO Employee + Children 269.52 257.27 246.08 235.83 226.40 217.69Medical Cigna PPO Employee + Family 541.07 516.48 494.02 473.44 454.50 437.02Medical Cigna PPO Joint Employee + Children 152.25 145.33 139.01 133.22 127.89 122.97Dental CompBenefit C250 Employee Only 4.70 4.48 4.29 4.11 3.95 3.79Dental CompBenefit C250 Employee + 1 Dep 8.94 8.53 8.16 7.82 7.51 7.22Dental CompBenefit C250 Employee + 2 or More 12.54 11.97 11.45 10.97 10.53 10.13Dental CompBenefit C150 Employee Only 6.95 6.63 6.34 6.08 5.84 5.61Dental CompBenefit C150 Employee + Dep 12.89 12.31 11.77 11.28 10.83 10.41Dental CompBenefit C150 Employee + 2 or More 18.85 17.99 17.21 16.49 15.83 15.22Vision Employee Only 0.00 0.00 0.00 0.00 0.00 0.00Vision Employee + 1 Dep 3.87 3.70 3.54 3.39 3.25 3.13Vision Employee + Family 8.49 8.10 7.75 7.43 7.13 6.85Employee Life Insurance (See Paycheck) * * * * * *Accidental Death & Dismemberment (See Paycheck) * * * * * *Short Term Disability (See Paycheck) * * * * * *Long Term Disability (See Paycheck) * * * * * *Long Term Care (See Paycheck) * * * * * *

**NO JOINT COVERAGE ALLOWED WHILE ON UNPAID LEAVE OF ABSENCE. (After exhaustion of Board paid portion)

*Your coverage elections are listed on your paycheck to verify cost-per-pay; cancellation of STD and/or LTD may require Evidence of Insurabilityin order to reinstate coverage; cancellation of 2 or more times life insurance must begin at 1 times life when you return.

Calculating Your MedicalPremiums

FMLA - The Medical premium you owe perpay period while on FMLA leave is theamount you might owe over and above theBoard paid benefits. To determine theamount you owe per pay period, find yourpay frequency (21, 22, 23, 24, 25, or 26) inthe Cost Estimator table below. Readdown the table until you come to yourcoverage election (e.g. Medical AetnaEmployee+ Spouse). From the Board PaidBenefits table, find the appropriate Boardpaid amount for your pay frequency andMedical insurer (e.g. Aetna). Subtract theamount in the Cost Estimator table fromthe Board Paid Benefits table.

The result will be your Medical cost perpay period while on FMLA leave.

IILOD - Board paid Medical,

Employee Only Vision, and 1 x EmployeeLife will be paid for up to 10 days. Anymedical premium you might owe over theBoard contribution is determined using thesame procedure as for FMLA leave above.

Illness Exhausted - Board paidMedical, Employee Only Vision, and 1 xEmployee Life will be paid up to 60 days.Any medical premium you might owe overthe Board contribution is determinedusing the same procedure as for FMLAleave above.

Workers Compensation - Anymedical premium you might owe over theBoard contribution is determined using thesame procedure as for FMLA leaveabove.

• Support Employees : Up to

75 days of Board paid Medical,Vision and 1 x Employee Life.

• Instructional &Administration : Up to 60days of Board paid Medical,Vision, and I x EmployeeLife.

*Health & DependentReimbursement Info:http://www.fbmc-benefits.com/Click on Section 125 Cafeteria Log-Inand follow instructions.

*Current Employee BenefitCoverage Info:http://www.easybenefits.com/ YouMUST have your personal SSN & PINnumber to enter this site.

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NOTE: "Waiver of Premium" - After an employee has an approved LTD claim, the employee no longer has to pay STD or LTD premiums.

Brevard Public Schools Leaves Of Absence Policy

*·Employees shall not be absent from their assigned duties except as authorized by the Superintendent or designatedrepresentative. An employee who is willfully absent from duty without leave shall forfeit compensation for the time ofsuch absence. Contracts or appointments shall be subject to cancellation by the Board and the employee shall besubject to immediate dismissal.

* Employees should refer to the “Leave of Absence Procedure” for specific leave requirements. Web Address: http://benefits.brevard.k12.fl.us/LOA/LOAHome.htm

* Bargaining unit employees refer to appropriate contract.