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I understand In order to resume coverage upon my return to work I must submit a midyear change form to the HR department within 30 days of my return I will receive a COBRA notice and will have the option to continue coverage under the UIW/IWHS/SACHS plans by electing to pay the full cost of the insurance premium through COBRA. In-active Military Duty I understand that I may request time off for re-certification or annual training as required in order to maintain my military reserve status. I understand I must provide proper documentation to be approved for this type of leave. If available I may request vacation pay for time off taken during my in-active duty but I am not required.. Name PIDM Job Title Department Supervisor Employee Type Staff Administrator Faculty My leave will begin on and I anticipate being able to return to work on. Military Leave of Absence USERRA I have informed my supervisor and have attached a copy of my orders or will provide them as soon as they become available. Please check appropriate service type Active Military Duty I understand if I am called to active military duty for 30 or more days I will be immediately covered in full by the military health system* If I am currently enrolled in UIW/IWHS/SACHS medical benefits plans my elected coverage will cease. Dependents of employees called to active duty for 30 or more days are immediately eligible but must apply to the TRICARE health benefits program of the Department of Defense. I understand In order to resume coverage upon my return to work I must submit a midyear change form to the HR department within 30 days of my return I will receive a COBRA notice and will have the option to continue coverage under the UIW/IWHS/SACHS plans by electing to pay the full cost of the insurance premium through COBRA. In-active Military Duty I understand that I may request time off for re-certification or annual training as required in order to maintain my military reserve status. I understand I must provide proper documentation to be approved for this type of leave. If available I may request vacation pay for time off taken during my in-active duty but I am not required*. Name PIDM Job Title Department Supervisor Employee Type Staff Administrator Faculty My leave will begin on and I anticipate being able to return to work on. Military Leave of Absence USERRA I have informed my supervisor and have attached a copy of my orders or will provide them as soon as they become available. Military Leave of Absence USERRA I have informed my supervisor and have attached a copy of my orders or will provide them as soon as they become available. Please check appropriate service type Active Military Duty I understand if I am called to active military duty for 30 or more days I will be immediately covered in full by the military health system* If I am currently enrolled in UIW/IWHS/SACHS medical benefits plans my elected coverage will cease. Please check appropriate service type Active Military Duty I understand if I am called to active military duty for 30 or more days I will be immediately covered in full by the military health system* If I am currently enrolled in UIW/IWHS/SACHS medical benefits plans my elected coverage will cease. Dependents of employees called to active duty for 30 or more days are immediately eligible but must apply to the TRICARE health benefits program of the Department of Defense.

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