Forms

Family and Medical Leave Fact Sheet - This sheet provides a summary of Family and Medical Leave facts.
Family Medical Leave: Your Rights and Responsibilities - Provides basic information about leave laws including, qualifying reasons, types of leaves available, rights and responsibilities of the employee and the employer, questions and answers, and a checklist of responsibilities for both the employee and the supervisor.
FMLA/CFRA/PDL Employee and Supervisor Responsibilities - Provides information for the employee and supervisor regarding their responsibilities during an employee's family and medical leave.
Request for Family and Medical Leave - Employee and/or Supervisor complete(s) this form. It outlines qualifying leave reasons and notifies the employee of types of leave that can be designated, employee's insurance obligations, and allows election to use compensatory time or annual leave.
Medical Certification Request - This form is provided with the Request for Family and Medical Leave form. A health care provider must certify the serious health condition necessitating the leave by completing the Medical Certification Request form.
Notification of Leave Placement/Non-Placement - This form is sent to an employee to notify them of "preliminary" or "final" leave designation, or denial of leave request.
Retention of Insurance - Provides employee with information regarding insurance retention and cost of employee's share of premiums during an unpaid leave.
Leave Follow-up Notification - Notifies the employee when leave is about to end and prepares him/her for what is needed upon return or how to request an extension.
Use of Accruals for Paid Family and Medical Leave - Form lists the paid leave time that must be used, if available, for FMLA, CFRA and PDL. Form also lists the appropriate time reporting codes for an employee's timesheet.
Supervisors Guide to Employees Leave
Official Leave of Absence Request

Lincoln Financial Basic Life Insurance Certificate(All SEIU & LIUNA employees have this coverage, paid for by the County.)
Lincoln Financial Beneficiary Designation Form
Lincoln Financial Enrollment Form for Group Insurance
Lincoln Financial Evidence of Insurability
Lincoln Financial Life Insurance Claim Form
Lincoln Financial Supplemental Life Insurance Certificate (SEIU & LIUNA employees who elect this coverage; it is voluntary, and 100% paid for by employee.)
Lincoln Financial Portability/Conversion Summary
Lincoln Financial Conversion Form
Lincoln Financial Portability Form
Standard Life Insurance Beneficiary Form
Standard Life Insurance Certificate
Standard Life Insurance Claim Form
Standard Life Insurance Evidence of Insurability
Standard/Supplemental Life Benefits Summary
Standard/Supplemental Life Enrollment Form
Standard Life Portability Application
Standard Life Conversion Application

2008 Retiree Benefit Election Form

VEBA Claim Form

VEBA Systematic Payment Form

Blue Shield Medicare Enrollment Form

Post Employment Program Election Form (Mgmt, Conf, Unrep, DDAA and LEMU Only)

Post Employment Program Election Form (LIUNA and SEIU Only)

Enrollment/Change Form

Reimbursement Claim Form

Medical Eye Services Claim Form