Other Paid

Personal(*2 school year maximum)

Sick(In excess of 5 consecutive days attach a doctor's note)

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

Family Medical (FMLA) ** *Medical Certification from doctor *FMLA eligibility form (Teachers exempt)

The School Board Of Brevard County2700 Judge Fran Jamieson Way

Viera, FL 32940-6699

LEAVE of ABSENCE REQUEST

Run #

Today's Date:

(Must match Board approved job description title)

Hours Worked

Employee's ID#

National BoardSick Bank Union

UNPAID LEAVE *PayrollCode

TotalHours

TotalDays

EndDate

StartDate

Military (Reserve/National Emergency Duty-attach orders) MLN

Field Trip Court Other 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 FMLA

NILor

LOAReceiving Workers' Compensation (WC)

FMLSelf Family Member BPS Employee for 12 mo.Meets 1,250 hrs

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

LOA

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

Professional Study LOA

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 Boardpaid 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 Boardpaid medical only benefit. I understand since I am not receiving a paycheck, that I must pay for my benefits to continue my coverage. (Please see chart on back of form.)

Initial

ACKNOWLEDGEMENTS FOR UNPAID LEAVES ~ ALL employees MUST initial below and sign form to complete this request*Enter payroll code in the time exception until position has been ended

Signature of Employee: Date:

MY SIGNATURE SIGNIFIES THAT I HAVE READ THE INFORMATION ON THE REVERSE SIDE OF THIS FORM, SPECIFICALLY MY RIGHTS UNDER THE FAMILY MEDICALLEAVE ACT (FMLA). I CERTIFY THAT THE INFORMATION SUBMITTED ON THIS REQUEST IS ACCURATE.

I wish to continue my current benefit elections by making proper payments to Brevard County School Board, 321-633-1000 ext. 248, otherwise they will be cancelled.(See Cost Estimator, next page)

NOYES

PAID LEAVE

Receiving Workers' Compensation (WC)

Injury in the Line of Duty (10 days maximum PAID per fiscal year)PIL

Military (Reserve/National Emergency Duty-attach orders) MIL

Self Family Illness/Death _________ SCK

_________ ***

JUR

*PayrollCode

TotalHours

TotalDays

EndDate

StartDate

Leave Approved Disapproved

Leave Approved Disapproved

Principal/Admin/Supv ____________________________________________________________

Human Resources Administrator ___________________________________________________

** Copies: Payroll/Employee/DepartmentBLUE INK ONLY** LOA Original: Compensation & Benefits (5 days or less retain at school/dept.)

School/Dept. Name & #

Job Title:

Home Address, City, State, Zip

Employee's (Legal) Name:

Request Type

Pay Type

Position Type:

School/Dept. #

Calculating Your MedicalPremiums

*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 ordesignated representative. An employee who is willfully absent from duty without leave shall forfeitcompensation for the time of such absence. Contracts or appointments shall be subject to cancellation bythe Board and the employee shall be subject to immediate dismissal.

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

Bargaining unit employees refer to appropriate contract.

Cost Estimator for 2008 Gross Benefit Premiums for Employees on PAID LOAUNPAID LOA you need to add the Board portion that shows on your pay stub to the amounts below

21 Pay 22 Pay 23 Pay 24 Pay 25 Pay 26 PayMedical BlueCare & CIGNA EPO Employee Only 12.38 11.82 11.31 10.84 10.40 10.00Medical BlueCare & CIGNA EPO Emp + Spouse 205.07 195.75 187.24 179.44 172.26 165.63Medical BlueCare & CIGNA EPO Emp + Children 110.44 105.42 100.84 96.64 92.77 89.20Medical BlueCare & CIGNA EPO Emp + Family 272.27 259.89 248.59 238.24 228.71 219.91Medical BlueCare & CIGNA EPO Joint EE + Children 21.62 20.63 19.74 18.92 18.16 17.46

Medical Cigna Basic Employee Only 0.00 0.00 0.00 0.00 0.00 0.00Medical Cigna Basic Employee + Spouse 73.61 70.27 67.21 64.41 61.83 59.46Medical Cigna Basic Employee + Children 52.77 50.37 48.18 46.18 44.33 42.62Medical Cigna Basic Employee + Family 196.04 187.13 178.99 171.54 164.67 158.34Medical Cigna Basic Joint Employee + Children 15.56 14.85 14.21 13.62 13.07 12.57

Medical BlueChoice & CIGNA PPO Employee Only 24.73 23.60 22.58 21.64 20.77 19.97Medical BlueChoice & CIGNA PPO Emp + Spouse 230.44 219.97 210.40 201.64 193.57 186.12Medical BlueChoice & CIGNA PPO Emp + Children 124.15 118.51 113.36 108.64 104.29 100.28Medical BlueChoice & CIGNA PPO Emp + Family 313.41 299.17 286.16 274.24 263.27 253.14Medical BlueChoice & CIGNA PPO Joint EE +Children 42.19 40.28 38.53 36.92 35.44 34.08

Delta DeltaCare Low DHMO Employee Only 4.83 4.61 4.41 4.23 4.06 3.90Delta DeltaCare Low DHMO Employee + 1 Dependent 7.98 7.62 7.29 6.99 6.71 6.45Delta DeltaCare Low DHMO Employee + 2 or More 11.81 11.27 10.78 10.33 9.92 9.54

Delta DeltaCare High DHMO Employee Only 8.34 7.96 7.61 7.30 7.00 6.73Delta DeltaCare High DHMO Employee + 1 Dependent 15.48 14.78 14.13 13.55 13.00 12.50Delta DeltaCare High DHMO Employee + 2 or More 22.62 21.59 20.65 19.79 19.00 18.27

Delta Dental Low PPO Employee Only 13.88 13.25 12.67 12.15 11.66 11.21Delta Dental Low PPO Employee + 1 Dependent 27.53 26.28 25.14 24.09 23.13 22.24Delta Dental Low PPO Employee + 2 or More 40.46 38.62 36.94 35.41 33.99 32.68

Delta Dental High PPO Employee Only 17.57 16.77 16.04 15.37 14.76 14.19Delta Dental High PPO Employee + 1 Dependent 34.85 33.27 31.82 30.50 29.28 28.15Delta Dental High PPO Employee + 2 or More 51.22 48.89 46.76 44.82 43.02 41.37

Vision Employee Only 0.00 0.00 0.00 0.00 0.00 0.00Vision Employee + 1 Dependent 3.87 3.70 3.54 3.39 3.25 3.13Vision Employee + Family 8.49 8.10 7.75 7.43 7.13 6.85Dependent Life Insurance $5,000: ea child $2,500 1.72 1.64 1.57 1.51 1.44 1.39Dependent Life Insurance $10,000: ea child $2,500 3.33 3.18 3.04 2.92 2.80 2.69

Employee 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, SECTION 125, IMPUTED INCOME OR FSA DEPENDENT DAY CARE 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 Insurability in order to reinstate coverage;Cancellation of 2 or more times life insurance must begin at 1 times life when you return.

FMLA - The Medical premium you oweper pay period while on FMLA leave is theamount you 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)in the Cost Estimator Table. Read downthe table until you come to your coverageelection (e.g. Medical Cigna EPOEmployee + Spouse). Then find theappropriate pay frequency. The result willbe your Medical cost per pay period whileon FMLA leave.

IILOD - Board paid Medical, EmployeeOnly Vision, and 1 x Employee Life will bepaid for up to 10 days. Any medicalpremium you might owe over the Boardcontribution is determined using the sameprocedure 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 determined usingthe same procedure as for FMLA leaveabove.

Workers Compensation - Anymedical premium you might owe over theBoard contribution is determined using thesame procedure as for FMLA leaveabove. • Support Employees : Up to 75days of Board paid Medical, Vision and 1x Employee Life. • Instructional & Administration :Up to 60 days of Board paid Medical,Vision, and I x Employee Life.

*Health & Dependent ReimbursementInfo:http://www.teamcornerstone.com/bps

Cost Estimator Table