LEAVE OF ABSENCE (LOA) REQUEST FORM
Chuze offers leave of absences for expecting parents, employees that need to care for themselves or an eligible family member, and for employees that are currently serving or will be serving in the US Armed Forces. Eligibility requirements must be met for some of the leave programs and depending on an employee’s geographical location, some leave programs may not be available. Regardless of the reason, we want to make sure that employees are fully aware of their options, how the leave process works, and most importantly, that they are fully supported throughout the leave process by the benefits team and their leadership team. Please complete this HIPPA compliant form to begin the LOA process.
Who is completing this request?
*
Please Select
Self/Employee
Employee Manager
Employee Name (in ADP)
*
First Name
Last Name
Employee Job Title
*
Club Name
*
Worker Category/Employment Status
*
Part Time
Full Time
Does the employee needing a leave have employees reporting to them? ("Reports to Manager" in ADP)
*
Yes
No
Employee Email
*
example@example.com
Manager Email
*
example@example.com
What type of Leave of Absence is being requested?
*
Please Select
Pregnancy/Baby Bonding
Own serious health condition
Family member's serious health condition
Military
Back
Next
Pregnancy
This request will require a pregnancy medical certification to be completed by your medical provider. Please discuss with your leadership team, any workplace accommodations that you may need during your pregnancy. You will be notified if you are eligible for baby bonding leave. You do not need to make a separate request.
Baby Bonding
This request is usually for the non-pregnant parent only. This request will not require a medical certification. Please provide leave start date and leave end date. You can provide the due date only if you have it, but it is not required as the non-pregnant parent.
Anticipated Leave Start Date
*
-
Month
-
Day
Year
Date
Anticipated Due Date
-
Month
-
Day
Year
Date
Anticipated Leave End Date
-
Month
-
Day
Year
Date
Pregnancy leave only: Please download required medical certification. The document will need to be completed by your doctor and returned to the Benefits team. (If you already have a doctors note or medical certification please upload it below)
Doctors Note/Medical Certification UPLOAD
Upload a File
Drag and drop files here
Choose a file
If you have a doctors note or medical certification please upload it here now.
Cancel
of
Back
Submit
Next
Serious Health Condition
This request will require a medical certification to be completed. A “serious health condition” means an illness, injury (including, but not limited to, on-the-job injuries), impairment, or physical or mental condition of the employee that involves either inpatient care or continuing treatment, including, but not limited to, treatment for substance abuse. A serious health condition may involve one or more of the following: hospital care, absence plus treatment, chronic conditions requiring treatment, long-term conditions, etc.
Leave Start Date
*
-
Month
-
Day
Year
Date
Leave End Date
-
Month
-
Day
Year
Date
Medical Certification
Medical documentation will need to be completed by a doctor and returned to the Benefits team within 15 days. If you already have a doctors note or medical certification please upload it below. If you do not have a medical certification please download the required document per your state below.
CALIFORNIA ONLY: Please download required medical certification. (If you already have a doctors note or medical certification please upload it below)
ARIZONA, COLORADO, NEW MEXICO, TEXAS, FLORIDA, GEORGIA: Please download required medical certification. (If you already have a doctors note or medical certification please upload it below)
Doctors Note/Medical Certification UPLOAD
Upload a File
Drag and drop files here
Choose a file
If you have a doctors note or medical certification please upload it here now.
Cancel
of
Back
Submit
Next
Military
Thank you for your service! USERRA (Uniformed Service Employment and Reemployment Act) allows employees who are currently serving in the US Armed Forces or planning to service in the US Armed Forces, to take unpaid leave for military related duties (i.e., deployment, training, etc.). Documentation/Orders are required for military leave longer than 31 days.
What type of service will you be fulfilling?
*
If your service is exempt from the 5-year USERRA period, please indicate the service exemption below. If your service is not exempt from the 5-year USERRA period, please type N/A below.
*
What type of service will the employee be fulfilling (if you are unsure, please ask employee)?
*
If the employee service is exempt from the 5-year USERRA period, please indicate the service exemption below. If the service is not exempt from the 5-year USERRA period, please type N/A below (if you are unsure, please ask employee).
*
Leave Start Date
*
-
Month
-
Day
Year
Date
Leave End Date
-
Month
-
Day
Year
Date
Documentation/Orders
Upload a File
Drag and drop files here
Choose a file
If you have a orders please upload it here now.
Cancel
of
Back
Submit
Next
Family Member's Serious Health Condition
This request will require a medical certification to be completed. A “serious health condition” means an illness, injury (including, but not limited to, on-the-job injuries), impairment, or physical or mental condition of the employee's family member that involves either inpatient care or continuing treatment, including, but not limited to, treatment for substance abuse. A serious health condition may involve one or more of the following: hospital care, absence plus treatment, chronic conditions requiring treatment, long-term conditions, etc.
Who is the family member in need of care?
*
Leave Start Date
*
-
Month
-
Day
Year
Date
Leave End Date
-
Month
-
Day
Year
Date
Medical Certification
Medical documentation will need to be completed by a doctor and returned to the Benefits team within 15 days. If you already have a doctors note or medical certification please upload it below. If you do not have a medical certification please download the required document per your state below.
CALIFORNIA ONLY: Please download required medical certification. (If you already have a doctors note or medical certification please upload it below)
ARIZONA, COLORADO, NEW MEXICO, TEXAS, FLORIDA, GEORGIA: Please download required medical certification. (If you already have a doctors note or medical certification please upload it below)
Doctors Note/Medical Certification UPLOAD
Upload a File
Drag and drop files here
Choose a file
If you have a doctors note or medical certification please upload it here now.
Cancel
of
Submit
Should be Empty: