May 20, 2024

YORK_START
DANICA LAZIC
132 SEMINARY DRIVE
DYER, IN 46311

Claim No: 2024-0066089

Employer: PENN Entertainment

Re: Family and Medical Leave Act (FMLA) Benefits

Dear DANICA:

Your Request

On April 15, 2024 Sedgwick, the claims administrator for PENN Entertainment, received your
request for Continuous leave under FMLA due to your need to care for your Parent who has a
serious health condition.

You notified us that you need the leave on the following dates:

Policy Absence Type Benefit Start Date Benefit End Date

FMLA Continuous June 18, 2024 September 9, 2024

Response to Your Request

Based on the information we have received, you are eligible for FMLA benefits from June 18,
2024 to September 9, 2024, subject to submission and confirmation of the Certification of
Health Care Provider and your leave being designated as FMLA.

What is Required of You by July 5, 2024

Authorization to Release Information for FMLA - Completion of this form is optional.

Should you decide to complete this form, please sign, date, and return to Sedgwick as soon
as possible.

Certification of Health Care Provider for Family Member's Serious Health Condition -
Must be completed by your health care provider and returned to Sedgwick by the paperwork
due date referenced in this letter. Failure to do so may result in your benefits being denied
until complete certification is provided.

Informational Brochures - For your information; need not be returned.

● Employee Portal Registration Instructions
● Employee Portal Promo Sheet
● PENN Entertainment Important Information About Your Leave_Non PIV Employees
Initial Status Letter Page 1 of 4
All completed forms must be returned to Sedgwick and can be sent via our secure fax at
(888) 436-9535. Once we obtain the information from you as specified above, we will inform
you of the benefit determination within 5 business days. Thank you for your prompt
attention.

If you have any questions, please feel free to contact me at, (877) 293-1353, Extension
57740.

Scan this QR code with your mobile device camera to go straight to Sedgwick’s Employee
Portal! New Users will be required to complete registration via desktop/laptop before
accessing the portal.

Sincerely,
Josie Erdy

Case Manager

Enclosure(s): Employee Portal Registration Instructions

Employee Portal Promo Sheet
Authorization to Release Information for FMLA
PENN Entertainment Important Information About Your Leave_Non PIV
Employees
Certification of Health Care Provider for Family Member's Serious Health
Condition

cc: PENN Entertainment Human Resources Department

Initial Status Letter Page 2 of 4

Your Rights and Responsibilities if You Are Eligible Under FMLA:

You have a right under FMLA for up to 12 workweeks of unpaid leave in a 12-month period
for the reasons listed above. Your health benefits must be maintained during any period of
unpaid leave under the same conditions as if you continued to work, and 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 leave. If you do not return to work following
FMLA leave for a reason other than: (1) the continuation, recurrence, or onset of a serious
health condition which would entitle you to FMLA leave; or (2) other circumstances beyond
your control, you may be required to reimburse your employer for their share of health
insurance premiums paid on your behalf during your FMLA leave.

1. If approved, the requested leave will be counted against your FMLA leave entitlement that
is calculated on a 12-month Rolling Backward method measured in one minute increments
and will run concurrently with other paid benefit programs offered by your employer.

2. You will be required to furnish the Certification of Health Care Provider by the date
referenced in this letter, or we may delay the commencement of your leave until the
certification is received. If certification is not received, we reserve the right to withdraw this
preliminary designation which may result in delay or denial of your leave, and you may be
subject to disciplinary action.

3. You are not required to use your available paid time off (such as PTO, vacation, sick,
personal or holiday time) during your absence. If your leave is certified, the leave will be
protected under FMLA and any concurrent state leave and counted against your entitlement.
Please refer to your PENN Entertainment Human Resource Department for further
information.

4. While on an approved leave, your employer will pay the employee portion of your health
insurance premiums. If payroll deductions for the premium payments cannot be made due to
insufficient earnings, contact your employer to discuss payment options. Upon your return to
work, any outstanding benefit premium balance will be deducted from your next available pay
cycle.

5. Your employer will pay the employee portion for other benefits (e.g., life insurance,
disability insurance, etc.) while you are on FMLA leave.

6. You will be required to furnish medical recertification of your own or your immediate
family member's serious health condition if you request leave beyond that specified in the
original certification. If such certification is required but not received, your continued FMLA
leave may be delayed until certification is provided.

7. If the circumstances of your leave change and you are able to return to work earlier than
the date indicated, you will be required to notify us as soon as reasonably possible.

8. You have been designated by your employer as a “key employee” as described in the
FMLA regulations. As such, restoration to employment may be denied following FMLA leave
on the basis that such restoration will cause substantial and grievous economic harm to your
employer. We have not determined that restoring you to employment at the conclusion of
FMLA leave will cause substantial and grievous economic harm to your employer. Please
contact your employer to make this determination.

Initial Status Letter Page 3 of 4

Initial Status Letter Page 4 of 4
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Employee Name: DANICA LAZIC Case Number: 2024-0066089
In order to substantiate your leave request under the Family and Medical Leave Act (FMLA) and/or State
FMLA, Sedgwick requires a health care provider certification (“FMLA Certification Form”) to support your need
for family and medical leave due to your own serious health condition or a family member’s serious health
condition. It is your responsibility to provide Sedgwick with a complete and sufficient certification. With your
permission, once the certification has been submitted, the FMLA regulations allow Sedgwick, as the
administrator of your employer’s FMLA policy, to seek clarification from your health care provider if it is
necessary to understand the meaning of a response or the handwriting on the medical certification.

I, DANICA LAZIC , hereby authorize Sedgwick to make contact with my, or my family
member’s, health care provider for the purpose of seeking authentication of the document or clarification of
the information contained in the document. This Release and Consent does not authorize the disclosure of: 1)
the identification of past, present, or future physical or mental health, or conditions; 2) the diagnosis or
treatment provided to me; 3) payment for the health care I received; or 4) genetic information. In addition,
Sedgwick will not, nor does this Release and Consent authorize Sedgwick to, request information beyond that
required by the FMLA Certification Form.

I understand, that I am responsible for signing any releases or authorizations required under the Health
Insurance Portability and Accountability Act (HIPAA) or other laws which would authorize the health care
provider to discuss my certification for leave and provide the clarifications requested.

I acknowledge that this authorization is voluntary, however if I choose not to provide Sedgwick with this
authorization, and do not provide either a complete and sufficient certification form Sedgwick may deny the
taking of FMLA leave.

I further understand that I have the right to revoke this authorization at any time by providing written notice
to Sedgwick at the following address:

Sedgwick
P.O. Box 182808
Columbus, OH 43218-2808

However, this authorization cannot be revoked if Sedgwick has taken action on this authorization prior to
receiving written notice. I also understand that I have a right to have a copy of this authorization. This
authorization is valid from the date of my signature below and shall expire one year from the date of this
authorization.

_____________________________ ___________
Employee Signature Date

We value your privacy. For more on what personal information we may collect, how we may use this
information and other important areas relating to your privacy and data protection, please read our privacy
notice www.sedgwick.com.
E M P L OY E E P O R TA L

Employees from
every job spectrum
have one thing
in common — us.

Our Employee Portal provides a convenient Self registration

and secure site for you to view your leave and
absence information. Any time day or night, Realtime claim status
you’ll have quick access to all your documents,
View all documentation
approvals and how much time you have available
for your leaves. Utilization calendar

Please visit us at https://timeoff.sedgwick.com to FAQ support

create your secure account or call our customer
Interactive messaging with representative
service team 888.436.9530.
Displays hours available for all leave types

Tracks multiple leaves simultaneously

 EMPLOYEE PORTAL

Registration instructions
https://timeoff.sedgwick.com

01
Once you are at the Login Screen, you’ll need to register
as a “User” to gain access to your account information.

Select the “Register Now” button and it will take you through
the simple process.

02
On the Registration Screen simply input your personal data
such as your Name, Date of Birth, Zip Code and the last
four digits of your Social Security Number.

03
The next step is to supply an email address and create
a secure password.

Passwords must be 7-15 characters in length and contain

letters and numbers.

04
After you enter an email address into the system,
it will generate a Validation Code for you to use.

Input your Validation Code in the spot provided

05
CONGRATULATIONS, your account is now active.

Access the Portal to review time spent or remaining

on your benefit plans, see updates to your case or open
a dialog with a customer service representative.

© 2019 Sedgwick
Caring counts. | sedgwick.com
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