This form is an application for Family and Medical Leave. It is to be filled out by an employee who is requesting a leave of absence.
New York Employee Application for FMLA
State:
Multi-State
Control #:
US-AHI-200
Format:
Word
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How to fill out Employee Application For FMLA?
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FAQ
The law allows employees wrongfully denied FMLA leave to file suit and if successful, recover damages for losses or harm suffered as a result. An employment attorney can help you file a legal claim against your employer to receive this compensation.
To apply for leave under FMLA, contact the personnel office of your employer agency. If eligible and approved, the personnel office will provide to the Fund's administrative office the appropriate information for continuation of Fund benefits.
The FMLA also states that employers must continue group health insurance coverage during the leave period. Employers cannot interfere with or deny an employee's right to leave. They also cannot discriminate against any person for reporting or complaining about an unlawful FMLA practice.
Employees are eligible for leave if they have worked for their employer at least 12 months, at least 1,250 hours over the past 12 months, and work at a location where the company employs 50 or more employees within 75 miles.
For 2020, you are allowed to take up to 10 weeks of Paid Family Leave in a 12-month period and you will receive 60% of your average weekly wage, capped at $840.70. That maximum amount, however, is equal to 60% of the State Average Weekly Wage of $1,401.17.
FMLA leave is unpaid, but employees may be allowed (or required) to use their accrued paid leave during FMLA leave. And, if you are taking leave for a reason covered by New York's temporary disability insurance or paid family leave programs, you may be eligible for benefits during your time off; see below.
To apply for FMLA, the employee must take an FMLA Medical Certification Form to their health care provider. This form ensures that the employee's or family member's applicable health condition is valid. After receiving the form, the employee must return it within 15 calendar days.
Upon return from FMLA leave, you will be placed in the same job or an equivalent position with status, benefits, and other employment terms and conditions restored. An employer may not interfere with, restrain, or deny the exercise of any right provided under FMLA.
In order to be eligible to take leave under the FMLA, an employee must (1) work for a covered employer, (2) work 1,250 hours during the 12 months prior to the start of leave, (3) work at a location where 50 or more employees work at that location or within 75 miles of it, and (4) have worked for the employer for 12
EligibilityHave worked for your employer for at least 12 months; and.Have worked for your employer for at least 1,250 hours in the 12 months before you are taking leave; and.Work at a location where your employer has at least 50 employees within 75 miles of your worksite.