The purpose of this Leave of Absence request form is to provide employees with a clear and consistent process for requesting a prolonged period of time away from work for qualifying personal, medical, family, military, or other approved reasons. This form helps ensure timely communication, proper documentation, and compliance with company policies and applicable leave laws while supporting employees during their time away from work. It also assists the company in coordinating operational needs, benefits administration, and return-to-work planning.

Resources:

Please complete the form fully with all known details.

The People Department will receive the form and reach out to you and your supervisor via email within 1 business day to confirm your request, ask any additional questions needed, and provide other information necessary for your leave.

MM slash DD slash YYYY
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Type of Leave(Required)
Employee benefits remain active while still on Leaves of Absences (those protected by federal/state laws) and employees are still required to pay their portion of the benefits. Rainbow has two options for employees to pay for their benefits while on their LOA; use their PTO to cover all/some of their benefits OR direct payment through bill pay.
Do you want to use your PTO to cover your deductions?(Required)
The People Department will inform you how much PTO you will have to cover your benefits and provide you with the options available to you.
Do you want your 401(k) deduction included in your benefit payment that is due during your leave?(Required)
Do you want your HSA deduction included in your benefit payment that is due during your leave?(Required)

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