[COMPANY] LETTER TO EMPLOYEES TO INITIATE …

1 P A S Associates has expertise in human resources and other areas involving employment issues. P A S Associates, in providing this form, does not represent that it is acting as an attorney or that it is giving any form of legal advice or legal opinion. P A S Associates recommends that before making any decision pertaining to human resource issues or employment issues, including the utilization of information contained on this website, the advice of legal counsel to determine the legal ramifications of the use of any such information be obtained. P A S Rev. 4/97 [ company ] LETTER TO EMPLOYEES TO INITIATE FMLA/CFRA LEAVE Date: Dear [ employee name]: You have been off work for _____ [days/hours] under circumstances we believe may qualify for leave under the Family and Medical Leave Act (FMLA) and the California Family Rights Act (CFRA). The purpose of this LETTER is to provide you with information and the forms that both you and your health care provider need to complete. The forms are to be returned to us so that we may determine if the absence(s) may be designated as FMLA/CFRA leave.

2 You are entitled to up to twelve weeks of family and medical leave in a 12-month period. You previously have used _____ [days/hours] of FMLA/CFRA during the current 12-month period and thus the total remaining FMLA available to you is _____ [days/hours]. According to the information we received, you may be able to return to work on _____ [date]. If, for any reason, you are unable to return to work, you must notify _____ at _____ [ company ] prior to the return date. If you fail to return to work at the end of the approved FMLA leave or if you fail to provide continued medical certification (not to exceed twelve weeks), we will not guarantee reinstatement to your previous position or any other position. Please remember: if you are off work due to your own illness or injury, you must provide the company with a medical release or fitness-for-duty certification to return to work prior to your return. As general information for you, during your FMLA leave the company does [allows/requires] the use of your accrued [sick, vacation, PTO] hours.

3 While on FMLA leave, your health benefits will continue for a maximum of twelve weeks. If you currently contribute to the payment of benefits, you must continue to do so while on leave, beginning on _____ [date]. The amount of each payment is $_____ and must be paid to the company . The payments will be due on or before the ____ [day] of each month. Your coverage will end on _____ if you do not return to work at which time you will be eligible for COBRA. Information pertaining to COBRA will be sent at that time. You will find enclosed a Request For Leave Of Absence form and a Certification Of Physician Or Practitioner For FMLA Leave form. Please return these forms to [ company ] on or before _____ [insert date, allow 15 days]. After receipt and review of the forms, we will make a determination on the designation of your absence as FMLA leave. Please contact _____ at _____ if you have any questions or would like any more information regarding FMLA leave or this information. We wish you the best and look forward to your return.

4 Sincerely, _____