Unpaid Leaves of Absence Form
Employee Benefits Corporation
Fax to: Mail to: Phone support:
E-mail support:
608 831 4790
Employee Benefits Corporation, PO Box 44347, Madison WI 53744-4347
800 346 2126 | 608 831 8445
[email protected]
Welcome to our enhanced Unpaid Leaves of Absence Form!
Unpaid Leaves of Absence Form
It’s been redesigned to allow you to easily select the leave that’s appropriate for
your participants. We hope you find it convenient to use.
Employee Bene its Corporation
Remember: Do not report a paid leave of absence. A paid leave does not result
in a permitted election change. Payroll deductions continue and the participant’s
Health Care and/or Dependent Care FSA and/or Individual Billed Insurance
Premium Account (IND) remain open.
Account Holder Information
Dates Governing The Unpaid Lea
Date the Unpaid Leave Begins (mm-dd
Please complete this form and return it to Em
Unpaid FMLA Leave of Absence
C
B.The first payroll after the leave begins that will be affected by the
unpaid leave
Revoke and Reinstate
•When the employee returns from their unpaid non-FMLA or
USERRA leave, please have them fill out a Permitted Election
Change Form to indicate what their FSA election is for the
remainder of the plan year
•Submit the completed form to
Employee Benefits Corporation
© 2014 Employee Benefits Corporation 106-11 04/14
er Unpaid Leave begins (mm-dd-yyyy)
pants are regarded as being employed throughout
3
s Corporation BEFORE the participant’s unpaid leave begins.
D
The participant wi l not make up deductions during the leave. The number of missed deductions w ll reduce the annual maximum
election amount that is available to reimburse medical expenses.
The participant revokes the election during the leave and reinstates the election at the same annual maximum. The employer may
adjust the participant’s paycheck deductions to reflect this change.
B. Keep the Plan Open Until the Participant Returns from Leave OR Exhausts the Maximum FMLA Period
The participant w ll make up deductions missed during the Unpaid FMLA Leave of Absence. Claims incurred during the Unpaid FMLA Leave of Absence are reimbursable.
Please elect one of the payment options below:
Catch Up
E
Pre-Pay
Pay As You Go
C
The participant wi l make up the required payments on a pre-tax basis when returning from the leave and within the plan year.
If the pre-pay or pay as you go option is elected and the participant fails to make payments the employer may use catch up to
collect missed payments. This option may not be ava lable if your leave crosses between two plan years.
The participant wi l pre-pay the deductions that would be due while on leave. This can be done on a pre-tax basis up to the end of
the plan year.
The participant wi l make payments to the employer to cover deductions while on leave. This is done on an after tax basis.
C. Revoke the election, AND allow the Plan to Terminate
This will terminate the plan and the participant has 3 months from the date the Unpaid FMLA Leave of Absence begins to submit claims for expenses incurred
prior to the start of the leave.
If h
id l
d b
d h FMLA
i
i d
l
b
d b FMLA d b
id
FMLA l
Unpaid Leaves of Absence Form
E.If the Plan Is Left Open, choose one of the payment options
J. If the Plan Is Left Open, choose one of the payment options
B
A. Revoke the election, AND reinstate the election upon return from leave
This option is available only if the participant returns from leave prior to exhausting the maximum FMLA period. Claims incurred during the Unpaid FMLA Leave of
Absence are NOT reimbursable.
C
D.If the Revoke and Reinstate option is elected, choose one of
the deductions options
I.Whether the employee wishes to revoke or leave open the
Health Care FSA
First Affected Pa
During an Unpaid FMLA Leave of Absence, there are three options for the Health Care FSA election. Please elect one of the three options below:
Revoke and Prorate
C.Choose one of the three election options for how the participant wants
their Health Care FSA affected by the unpaid FMLA leave
5.If the unpaid leave is covered by USERRA, indicate:
Date the Unpaid Leave Ends (mm-dd-yyyy)
Org ID
Please elect one of the options below:
3.If the leave affects the Health Care FSA or Limited Health Care FSA, and is
covered by FMLA, complete the Unpaid FMLA Leaves of Absence section.
Unpaid FMLA Leaves of Absence DO NOT apply to the Dependent Care FSA or
IND account.
H.If Eligibility to participate in the FSAs is not lost choose one of
the payment options
Employer
An Unpaid FMLA Leave of Absence only affe
h Care FSA. For the Dependent Care FSA and/or IND account and unpaid leaves that extend beyond the FMLA
maximum period use the Non-FMLA Unpaid Lea e of Absence section of this form.
A.The first and last day of the unpaid leave and if the last day of the unpaid
leave is unknown, leave that date blank
G.If revoking the Dependent Care FSA and/or IND election, and/or
keeping the Health Care FSA open through COBRA, choose one
of the payment options
Name
There are three different types of unpaid leaves of absence: (1) Unpaid Family and Medical Leave Act (FMLA) leaves of absence; (2) non-FMLA unpaid leaves of absence; and
(3) Uniformed Services Employment and Reemployment Rights Act (USERRA) unpaid leaves of absence. Please note that each type of leave is subject to different regulations and
w ll affect participant benefits differently. If a participant decides to continue or revoke their elections it w ll affect the BESTflexSM Plan.
2.In the section Dates Governing the Unpaid Leave, indicate:
F.If Eligibility to participate in the accounts is lost choose
“Revoke My Elections” or “Revoke My Dependent Care and IND
Election” only
A
Last 4 Digits of Social Security or Identification Number
Required)
If the leave of absence is paid, do not c
this form. Paid leaves of absence are not considered a qual fying event
the leave and no changes may occur unless another qualifying event occurs.
1.Complete the Account Holder Information.
4.In the section Non-FMLA Unpaid Leave of Absence, indicate:
2
E-mail Address (we do not share e-ma l addresse
Form Page 1
Form Page 2
1
Last Name
Some tips to remember when completing the Unpaid Leaves of Absence Form
with your employees:
•If the participant does not return to work prior to exhausting the
maximum FMLA period (e.g., the leave is longer than 12 weeks),
the remaining portion of the leave is an unpaid leave (no longer
subject to FMLA) and the employee should complete another form
for that portion of the leave
608 831 4790
Employee Benefits Corporation PO Box 44347 Madison WI 53744-4347
800 346 2126 | 608 831 8445
employerservices@ebcflex com
Fax to:
Mail to:
Phone support:
E-mail support:
Employee Benefits Corporat on
Fax to:
Mail to:
Phone support:
E-mail support:
Non-FMLA Unpaid Leave of Absence
608 831 4790
Employee Benefits Corporation, PO Box 44347, Madison WI 53744-4347
800 346 2126 | 608 831 8445
[email protected]
During an unpaid non-FMLA leave, the participant m
If no eligib lity is lost, the participant must make up any
4
tions only if the leave of absence causes a loss of eligibility for benefits.
deductions. Please elect one of the two options below:
A. Eligib lity is lost
The participant is on a Non-FMLA Unpaid Leave of Absence and is not eligible to participate in the BESTflex Plan. Please elect one of the options below:
The participant has 3 months to submit Health Care FSA and/or IND expenses that were incurred prior to the start of the
Revoke my election(s)
F
Revoke my Dependent Care
election and/or keep my Health Care
FSA open through COBRA
Non-FMLA Unpaid Leave of Absence. The participant has until the end of the plan year to submit e ig ble Dependent Care FSA
expenses that were incurred anytime during the plan year.
The participant has until the end of the plan year to submit eligible Dependent Care FSA expenses that were incurred anytime
during the plan year and 3 months to submit ND expenses that were incurred prior to the start of the non-FMLA Unpaid
Leave of Absence. The participant w ll make up missed Health Care FSA deductions during the leave through COBRA.
This will a low the submission of Health Care FSA expenses during the leave and have the annual election amount available.
Please elect one of the payment options below to keep the Health Care FSA open through COBRA:
Catch Up
The participant w ll make up the required payments on a pre-tax basis upon returning from the leave and within the plan
year. The employer and participant must agree upon this payment option in ADVANCE of the leave. This option may not be
ava lable if your leave crosses between two plan years.
The participant w ll pre-pay the deductions that would be due wh le on leave. This can be done on a pre-tax basis up to the
end of the plan year.
The participant w ll make payments to the employer to cover deductions while on leave. This is done on an after tax basis.
G
Pre-Pay
Pay As You Go
B. Elig bility is not lost by the unpaid non-FMLA leave (Health Care, Dependent Care FSA and/or IND) No changes to participant elections w ll be made.
Please elect one of the payment options below.
Catch Up
H
Pre-Pay
Pay As You Go
USERRA Unpaid Leave of Absence
The participant w ll make up the required payments on a pre-tax basis upon returning from the leave and within the plan
year. The employer and participant must agree upon this payment option in ADVANCE of the leave. This option may not be
ava lable if your leave crosses between two plan years.
The participant w ll pre-pay the deductions that would be due wh le on leave. This can be done on a pre-tax basis up to the
end of the plan year.
Th
ant w ll make payments to the employer to cover deductions while on leave. This is done on an after tax basis.
5
USERRA mandates COBRA-l ke provisions to protect vetera
ealth benefits while away from employment. If the participant leaves employment for service in the mi itary
the participant is entitled to health coverage as well as his or her dependents for a period equal to the lesser of:
( ) 24 months beginning on the date on which the USERRA Unpaid Leave of Absence begins; or (2) the day after the date on which failure to apply for or return to employment occurs.
If the participant is gone for more than 31 days the employer may charge up to 102% of the premium normally charged. However if the participant serves less than 31 days the
employer may only charge the amount the participant is normally responsible to pay for the premium. f the participant chooses not to make up the deductions the plan year w ll end
and the participant must wait unt l the n
ar to enro l.
Please elect one of the two options bel
A. Revoke my Health Care FSA Ele
I
he participant has 3 months to submit Health Care FSA claims for expenses incurred prior to the start of the leave.
B. Keep my Health Care FSA Plan Open Please elect one of the payment options below (with my employer’s approval):
J
Pre-Pay
The participant w ll make up the required payments on a pre-tax basis upon returning from the leave and within the plan year.
The employer and participant must agree on this payment option in ADVANCE of the leave. This option may not be available if
your leave crosses between two plan years.
The participant w ll pre-pay the deductions that would be due wh le on military leave. This can be done on a pre-tax basis up
to the end of the plan year.
Pay As You Go
The participant w ll make payments to the employer to cover deductions while on leave. This is done on an after tax basis.
Catch Up
Signatures:
By:
Employee Signature
By:
Payroll/HR Officer Signature
Print Name
Print Name
Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
Please keep a copy for your records
© 2014 Employee Benefits Corporation
106-11 04/14
Unpaid Leaves of Absence Form
Employee Benefits Corporation
Fax to: Mail to: Phone support:
E-mail support:
608 831 4790
Employee Benefits Corporation, PO Box 44347, Madison WI 53744-4347
800 346 2126 | 608 831 8445
[email protected]
Account Holder Information
Last 4 Digits of Social Security or Identification Number
(Required)
Last Name
First Name
E-mail Address (we do not share e-mail addresses)
Employer
Org ID
Dates Governing The Unpaid Leave
Date the Unpaid Leave Begins (mm-dd-yyyy)
Date the Unpaid Leave Ends (mm-dd-yyyy)
First Affected Payroll Date after Unpaid Leave begins (mm-dd-yyyy)
If the leave of absence is paid, do not complete this form. Paid leaves of absence are not considered a qualifying event. Participants are regarded as being employed throughout
the leave and no changes may occur unless another qualifying event occurs.
There are three different types of unpaid leaves of absence: (1) Unpaid Family and Medical Leave Act (FMLA) leaves of absence; (2) non-FMLA unpaid leaves of absence; and
(3) Uniformed Services Employment and Reemployment Rights Act (USERRA) unpaid leaves of absence. Please note that each type of leave is subject to different regulations and
will affect participant benefits differently. If a participant decides to continue or revoke their elections, it will affect the BESTflexSM Plan.
Please complete this form and return it to Employee Benefits Corporation BEFORE the participant’s unpaid leave begins.
Unpaid FMLA Leave of Absence
An Unpaid FMLA Leave of Absence only affects the Health Care FSA. For the Dependent Care FSA and/or IND account and unpaid leaves that extend beyond the FMLA
maximum period, use the Non-FMLA Unpaid Leave of Absence section of this form.
During an Unpaid FMLA Leave of Absence, there are three options for the Health Care FSA election. Please elect one of the three options below:
A. Revoke the election, AND reinstate the election upon return from leave
This option is available only if the participant returns from leave prior to exhausting the maximum FMLA period. Claims incurred during the Unpaid FMLA Leave of
Absence are NOT reimbursable.
Please elect one of the options below:
Revoke and Prorate
The participant will not make up deductions during the leave. The number of missed deductions will reduce the annual maximum
election amount that is available to reimburse medical expenses.
Revoke and Reinstate
The participant revokes the election during the leave and reinstates the election at the same annual maximum. The employer may
adjust the participant’s paycheck deductions to reflect this change.
B. Keep the Plan Open Until the Participant Returns from Leave OR Exhausts the Maximum FMLA Period
The participant will make up deductions missed during the Unpaid FMLA Leave of Absence. Claims incurred during the Unpaid FMLA Leave of Absence are reimbursable.
Please elect one of the payment options below:
Catch Up
The participant will make up the required payments on a pre-tax basis when returning from the leave and within the plan year.
If the pre-pay or pay as you go option is elected and the participant fails to make payments, the employer may use catch up to
collect missed payments. This option may not be available if your leave crosses between two plan years.
Pre-Pay
The participant will pre-pay the deductions that would be due while on leave. This can be done on a pre-tax basis up to the end of
the plan year.
Pay As You Go
The participant will make payments to the employer to cover deductions while on leave. This is done on an after tax basis.
C. Revoke the election, AND allow the Plan to Terminate
This will terminate the plan and the participant has 3 months from the date the Unpaid FMLA Leave of Absence begins to submit claims for expenses incurred
prior to the start of the leave.
If the unpaid leave extends beyond the FMLA maximum period, your leave ceases to be covered by FMLA and becomes an unpaid non-FMLA leave.
© 2014 Employee Benefits Corporation 106-11 04/14
Unpaid Leaves of Absence Form
Employee Benefits Corporation
Fax to: Mail to: Phone support:
E-mail support:
608 831 4790
Employee Benefits Corporation, PO Box 44347, Madison WI 53744-4347
800 346 2126 | 608 831 8445
[email protected]
Non-FMLA Unpaid Leave of Absence
During an unpaid non-FMLA leave, the participant may change elections only if the leave of absence causes a loss of eligibility for benefits.
If no eligibility is lost, the participant must make up any missed deductions. Please elect one of the two options below:
A. Eligibility is lost
The participant is on a Non-FMLA Unpaid Leave of Absence and is not eligible to participate in the BESTflex Plan. Please elect one of the options below:
Revoke my election(s)
Revoke my Dependent Care FSA, IND
election and/or keep my Health Care
FSA open through COBRA
The participant has 3 months to submit Health Care FSA and/or IND expenses that were incurred prior to the start of the
Non-FMLA Unpaid Leave of Absence. The participant has until the end of the plan year to submit eligible Dependent Care FSA
expenses that were incurred anytime during the plan year.
The participant has until the end of the plan year to submit eligible Dependent Care FSA expenses that were incurred anytime
during the plan year and 3 months to submit IND expenses that were incurred prior to the start of the non-FMLA Unpaid
Leave of Absence. The participant will make up missed Health Care FSA deductions during the leave through COBRA.
This will allow the submission of Health Care FSA expenses during the leave and have the annual election amount available.
Please elect one of the payment options below to keep the Health Care FSA open through COBRA:
Catch Up
Pre-Pay
Pay As You Go
The participant will make up the required payments on a pre-tax basis upon returning from the leave and within the plan
year. The employer and participant must agree upon this payment option in ADVANCE of the leave. This option may not be
available if your leave crosses between two plan years.
The participant will pre-pay the deductions that would be due while on leave. This can be done on a pre-tax basis up to the
end of the plan year.
The participant will make payments to the employer to cover deductions while on leave. This is done on an after tax basis.
B. Eligibility is not lost by the unpaid non-FMLA leave (Health Care, Dependent Care FSA and/or IND) No changes to participant elections will be made.
Please elect one of the payment options below.
Catch Up
Pre-Pay
Pay As You Go
The participant will make up the required payments on a pre-tax basis upon returning from the leave and within the plan
year. The employer and participant must agree upon this payment option in ADVANCE of the leave. This option may not be
available if your leave crosses between two plan years.
The participant will pre-pay the deductions that would be due while on leave. This can be done on a pre-tax basis up to the
end of the plan year.
The participant will make payments to the employer to cover deductions while on leave. This is done on an after tax basis.
USERRA Unpaid Leave of Absence
USERRA mandates COBRA-like provisions to protect veteran’s rights to health benefits while away from employment. If the participant leaves employment for service in the military,
the participant is entitled to health coverage as well as his or her dependents for a period equal to the lesser of:
(1) 24 months beginning on the date on which the USERRA Unpaid Leave of Absence begins; or (2) the day after the date on which failure to apply for or return to employment occurs.
If the participant is gone for more than 31 days, the employer may charge up to 102% of the premium normally charged. However, if the participant serves less than 31 days, the
employer may only charge the amount the participant is normally responsible to pay for the premium. If the participant chooses not to make up the deductions, the plan year will end
and the participant must wait until the next plan year to enroll.
Please elect one of the two options below:
A. Revoke my Health Care FSA Election. The participant has 3 months to submit Health Care FSA claims for expenses incurred prior to the start of the leave.
B. Keep my Health Care FSA Plan Open. Please elect one of the payment options below (with my employer’s approval):
Pre-Pay
The participant will make up the required payments on a pre-tax basis upon returning from the leave and within the plan year.
The employer and participant must agree on this payment option in ADVANCE of the leave. This option may not be available if
your leave crosses between two plan years.
The participant will pre-pay the deductions that would be due while on military leave. This can be done on a pre-tax basis up
to the end of the plan year.
Pay As You Go
The participant will make payments to the employer to cover deductions while on leave. This is done on an after tax basis.
Catch Up
Signatures:
By:
Employee Signature
By:
Payroll/HR Officer Signature
Print Name
Print Name
Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
Please keep a copy for your records
© 2014 Employee Benefits Corporation 106-11 04/14