This form provided by the Department of Administrative Services
PART C – RIGHTS AND RESPONSIBILITIES FOR TAKING FAMILY/MEDICAL OR
MILITARY FAMILY LEAVE
If your leave does qualify as family/medical leave or military family leave, you will
have the following responsibilities
while on leave:
• During your paid and/or unpaid family/medical leave, there will be no change in your existing benefits.
• The State will continue to pay the same portion of your individual and dependents’ health coverage as it did prior to the
• While on unpaid leave, you will be billed directly by __________________________________ for your portion of the cost.
• Federal FMLA provides employees on FMLA leave a minimum 30-day grace period in which to make premium payments.
• If payment is not made timely, federal law allows the state to cancel group health insurance, provided it notifies you in
writing at least15 days before the date that your health coverage will lapse,
Under federal law, the State has the option of paying your share of the premiums during federal FMLA leave, and recovering
these payments from you upon yo
ur return to work.
o (check one) The State ____will/ ____will not pay your share of health insurance premiums while you are on leave.
• If you have state-sponsored group life insurance and are unpaid leave, you will be billed at the same rate you were paying
prior to the leave.
• If you are having other deductions taken from your paycheck (e.g., disability insurance, BSL life insurance, credit union
loans, deferred compensation) you should contact the vendor directly to discuss payment options.
You will be required to use all of your available sick leave accruals during your family/medical leave absence if the absence is for
your own serious illness or injury. This means that you will use your sick leave accruals and the leave will also be considered
protected family medical leave and counted against your family medical leave entitlement.
While on leave, you will be required to furnish us with periodic reports of your status and intent to return to work every:
(Indicate interval of periodic reports, as appropriate for the particular leave situ
If the circumstances of your leave change, and y
ou are able to return to work earlier than the date indicated on the this form, you will be required
to notify us at least two workdays prior to the date you intend to report for work.
Unless otherwise specified in your labor contract, leaves of absence without pay are deducted from service credit for longevity
• You should consult your contract’s seniority article for information on whether the time spent on unpaid leave is creditable
toward general or layoff seniority.
• You should also consult your pension plan regarding time spent on unpaid leave.
Federal FMLA defines “key employee” as a salaried, FMLA-eligible employee who is among the highest paid 10 % of all the
employees working for the employer within 75 miles of the employee’s worksite.
• Under federal FMLA, the employer may deny individuals designated as a “key employee” reinstatement to their positions
following their FMLA leave.
The State of Connecticut does not design
ate any employees as “key employees” under federal FMLA.