Employee Name: ____________________________________________________________________________________________
Part C: Maintain Health Benefits
Your health benefits must be maintained during any period of FMLA leave under the same conditions as if you continued
to work. During any paid portion of FMLA leave, your share of any premiums will be paid by the method normally used
during any paid leave. During any unpaid portion of FMLA leave, you must continue to make any normal contributions to
the cost of the health insurance premiums. To make arrangements to continue to make your share of the premium payments
on your health insurance while you are on any unpaid FMLA leave, contact ____________________________ at
You have a minimum grace period of ( 30-days or _____________ indicate longer period, if applicable) in which to
make premium payments. If payment is not made timely, your group health insurance may be cancelled, provided we notify
you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your share
of the premiums during FMLA leave, and recover these payments from you upon your return to work.
You may be required to reimburse us for our share of health insurance premiums paid on your behalf during your FMLA
leave if you do not return to work following unpaid FMLA leave for a reason other than: the continuation, recurrence, or
onset of your or your family member’s serious health condition which would entitle you to FMLA leave; or the continuation,
recurrence, or onset of a covered servicemember’ s serious injury or illness which would entitle you to FMLA leave; or
other circumstances beyond your control.
Part D: Other Employee Benefits
Upon your return from FMLA leave, your other employee benefits, such as pensions or life insurance, must be resumed in
the same manner and at the same levels as provided when your FMLA leave began. To make arrangements to continue
your employee benefits while you are on FMLA leave, contact _______________________________________________
Part E: Return-to-Work Requirements
You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment
on your return from FMLA-protected leave. An equivalent position is one that is virtually identical to your former position
in terms of pay, benefits, and working conditions. At the end of your FMLA leave, all benefits must also be resumed in the
same manner and at the same level provided when the leave began. You do not have return-to-work rights under the FMLA
if you need leave beyond the amount of FMLA leave you have available to use.
Part F: Other Requirements While on FMLA Leave
While on leave you ( will be / will not 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 FMLA leave situation).
If the circumstances of your leave change and you are able to return to work earlier than expected,
you will be required to notify us at least two workdays prior to the date you intend to report for work.
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
It is mandatory for employers to provide employees with notice of their eligibility for FMLA protection and their rights and
responsibilities. 29 U.S.C. § 2617; 29 C.F.R. § 825.300(b), (c). It is mandatory for employers to retain a copy of this disclosure in their
records for three years. 29 U.S.C. § 2616; 29 C.F.R. § 825.500. Persons are not required to respond to this collection of information
unless it displays a currently valid OMB control number. The Department of Labor estimates that it will take an average of 10 minutes
for respondents to complete this collection of information, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments
regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send
them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution Avenue, N.W.,
Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THE DEPARTMENT OF LABOR. EMPLOYEE INFORMATION.
Page 4 of 4 Form WH-381, Revised June 2020