110 STAT. 4362 CONCURRENT RESOLUTIONS—APR. 16, 1996 us for our share of health insurance premiums paid on your behalf during your FMLA leave. This is to inform you that: (check appropriate boxes; explain where indicated) 1. You are D eligible D not eligible for leave under the FMLA as made applicable by the CAA. 2. The requested leave D will D will not be counted against your annual FMLA leave entitlement. 3. You D will D will not be required to furnish medical certification of a serious health condition. If required, you must furnish certification by (insert date) (must be at least 15 days after you are notified of this requirement) or we may delay the commencement of your leave until the certification is submitted. 4. You may elect to substitute accrued paid leave for unpaid FMLA leave. We • will D will not require that you substitute accrued paid leave for unpaid FMLA leave. If paid leave will be used the following conditions will apply: (Explain) 5(a). If you normally pay a portion of the premiums for your health insurance, these payments will continue during the period of FMLA leave. Arrangements for pay- ment have been discussed with you and it is agreed that you will make premium payments as follows: (Set forth dates, e.g., the 10th of each month, or pay periods, etc. that specifically cover the agreement with the employee.). (b). You have a minimum 30-day (or, indicate longer period, if applicable) grace period in which to make premium payments. If payment is not made timely, your group health insurance may be cancelled: Provided, That 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. We D will D will not pay your share of health insurance premiums while you are on leave. (c). We D will D will not do the same with other benefits (e.g., life insurance, disability insurance, etc.) while you are on FMLA leave. If we do pay your premiums for other benefits, when you return from leave you D will D will not be expected to reimburse us for the payments made on your behalf 6. You D will D will not be required to present a fitness-for-duty certificate prior to being restored to employment. If such certification is required but not received, your return to work may be delayed until the certification is provided. 7(a). You D are D are not a "key employee" as described in §825.218 of the Of- fice of Compliance's FMLA regulations. If you are a "key employee", restoration to employment may be denied following FMLA leave on the grounds that such restoration will cause substantial and grievous economic injury to us. (b). We D have D have not determined that restoring you to employment at the conclusion of FMLA leave will cause substantial and grievous economic harm to us. (Explain (a) and/or (b) below. See §825.219 of the Office of Compliance's FMLA regulations.) 8. While on leave, you D will D will not be required to furnish us with periodic reports every (indicate interval of periodic reports, as appropriate for the particular leave situation) of your status and intent to return to work (see § 825.309 of the Office of Compliance's FMLA regulations). If the circumstances of your leave change and you are able to return to work earlier than the date indicated on the reverse side of this form, you D will D will not be required to notify us at least two work days prior to the date you intend to report for work. 9. You D will D will not be required to furnish recertification relating to a serious health condition. (Explain below, if necessary, including the interval between certifications as prescribed in § 825.308 of the Office of Compliance's FMLA regulations.)
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