Unpaid Leave of Absence Request Form

An unpaid leave of absence is available in certain circumstances as described in [Company name]'s [insert policy name]. Employees who meet the eligibility criteria for a leave of absence must complete this form at least 30 days prior to the commencement of leave or as soon as practicable in the event of an unforeseeable absence. Please note:

• All leaves of absence must be approved in advance by human resources (HR) and the employee's supervisor.
• If the dates of requested leave change, a new leave of absence request form must be submitted for approval.
• Employees on an unpaid leave of absence are responsible for payment of insurance premiums as agreed upon with HR prior to the commencement of leave.
• Employees returning from a leave of absence must contact HR at least one week in advance of the projected return date.

See [insert policy name] for the full details on unpaid leaves of absence, including eligibility.

This form should not be used to request leave under the Family and Medical Leave Act (FMLA) or to request leave as an accommodation under the Americans with Disabilities Act (ADA). Employees should consult with HR to request leave under the FMLA or ADA.

To be completed by the employee:

Date of request: ______________   Employee name: _______________________            
Department: _________________     Job title: _____________________________
Date of hire: _________________

Employee status:  ( ) Exempt   ( ) Nonexempt   ( ) Full time   ( ) Part time

Requested leave dates (mm/dd/yy): ____________ to ____________.

Reason for the leave of absence: _______________________________________

__________________________________________________________________.

I have read and fully understand the information contained in [Company name]'s leave of absence policy.

________________________________________      _______________
Employee signature                                                            Date

To be completed by the employee's supervisor:

Leave request is: ____ Approved      ____ Not approved

If not approved, provide an explanation: __________________________________

__________________________________________________________________.

Supervisor signature: _____________________      Date: ____________________

To be completed by HR:

Leave request is: ____ Approved      ____ Not approved

If not approved, provide an explanation: __________________________________

__________________________________________________________________.

HR employee signature: _____________________  Date: ____________________

Employee's last day worked: __________    Employee's return-to-work date: __________

Insurance to be continued and the weekly/monthly cost to employee:

Total insurance premium due per week: $____________

Total insurance premium due per month: $___________

File original in the employee's leave records and provide a copy to the employee and the employee's supervisor.