Attached Forms

Download as pdf or txt
Download as pdf or txt
You are on page 1of 36

Important Information and Next Steps

Relating to your Leave of Absence


Once Your Leave is Approved

If your leave is approved under FMLA and/or applicable state leave(s), you will have certain rights and obligations in addition
to the information provided in the preceding letter and other enclosures. Please read this information carefully to be familiar
with the next steps and your obligations.

1. Notification of need for time off: You must notify us of any absences taken under the leave. Such notice must be (a)
given 30 days in advance or, if 30 days is not possible, then as soon as practicable if the need for leave is foreseeable.
Failure to provide the specified notice may result in a delay or denial of your leave.

2. Reporting during leave: You will be required to report periodically during your leave regarding your status and your intent
to return to work. If further medical certification is needed during your leave, we will advise you of that request.

3. Reporting procedures: Normal company policies regarding reporting absences, providing status reports, providing
notice of early return to work, and the like will apply, unless special circumstances make this impossible or
impracticable. In such case, you will be expected to report regarding your absence or your status as soon as
practicable after the usual deadline. This includes timing of reporting unless otherwise specifically designated for your
leave, method or reporting (e.g., verbal or written) and the person(s) to whom you must report.

4. Increase or change in leave times: If, following your initial request, you require a leave extension or more frequent
intermittent or reduced schedule leave, it is your responsibility to notify Alight as follows:

• Continuous leave: prior to the last authorized leave date if you are on a continuous leave; or
• Intermittent or reduced schedule leave: as soon as practicable, but no later than 15 days if you are on intermittent
or reduced schedule leave.

In either circumstance, additional information or certification may be required to support the increase or change in
leave.

5. Early return to work: If the circumstances of your leave change and you are able to return to work earlier than the date
indicated on your leave approval, you will be required to notify us in advance. Notification must be provided within two
workdays after the change in circumstance is known, and no later than two work days prior to the date you intend to
report to work. A release to return to work full duty must be provided to your manager and the Benefit Resource Center.

6. Counting of absences against leave benefits: All absences will be applied and counted concurrently toward your other
applicable leave laws, policies, and benefits to the extent permitted by law.

7. Leave year calculation method: Your leave is tracked against a rolling 12-month period measured backward from the
date you first took leave under FMLA and, if permitted by applicable law, under your state leave.

8. Use of paid time off during approved leave: FMLA and/or applicable state leave is unpaid time off. You are
required to use any accrued unused sick time concurrently with any unpaid portion of your FMLA leave. You can
also elect to use any accrued unused vacation time to cover all or part of the unpaid portion of your leave. If you
do not have enough accrued unused sick and/or vacation time to cover your entire leave, the portion that is not
covered will be unpaid leave.
9. Job protection: As long as your absences are pursuant to approved FMLA and/or state leave law, your job is
protected and you will be reinstated at the end of your leave to the same or an equivalent position, except as limited
by law. If you are considered a “key employee” as defined by the FMLA and/or state law, you will be notified and
provided additional information under separate cover.

10. Health care benefits: If your claim is for STD, FMLA, and/or applicable state leave, or personal and you are enrolled
in the Company’s group insurance program (health, dental, vision, life, etc.), you will be billed directly by WEX
Health. You will have a 30-day grace period to make the premium payments. Failure to make a timely payment
will result in cancellation of coverage. If you remain out on leave of absence for more than 180 days, your
benefits will be cancelled at the end of the month, unless otherwise prohibited by law, and you will be offered
COBRA from WEX.

11. 401(k) Benefits: While on “unpaid leave”, you will not have sufficient regular earnings via your paycheck to cover
your loan repayment. You MUST contact Charles Schwab retirement “plan” to request a loan repayment suspension.
Charles Schwab may grant a loan repayment suspension to help avoid a default on your loan. When unpaid leave
ends, the loan must be repaid. The plan may refinance your loan over the remaining period of the original loan
(which will increase your original payment amount.) Your other option is to pay off your loan before you begin your
leave of absence. Charles Schwab cannot extend your payment period beyond the original payoff date. Employees on
military leave will be permitted to refinance their loan over a period of remaining life of the loan (upon return), plus
the period of military service. Charles Schwab Participant Services can be contacted at 800-724-7526.

12. Return to Work:


If you have taken a medical leave, before you can return to work, you must submit documentation from your health
care provider certifying that you are able to return to work to your Manager and the Benefit Resource Center. A
Return-to-Work or Fit-for-Duty Certification form can be obtained by contacting Alight at 1.866.451.3399. If you
have taken a military leave, prior to returning to work, reach out to your Manager and the SCI Leave & Disability
Team.
If you have taken an Educational or Mortuary School leave, prior to returning to work, reach out to your Manager
and the SCI Leave & Disability Team. Additionally, when you are returning from an educational leave, you will need to
present the Company with sufficient proof of completion prior to reinstatement. The proof must certify that you
attended an accredited college or university on a full-time basis and successfully completed courses intended for
career development. A diploma, transcript, or letter of certification are acceptable forms of documentation. Documents
can be emailed to benefitservice.center@sci-us.com or faxed to (504) 729-1813.

SCIC-661-328700646869
AUTHORIZATION FOR PROVIDER’S RELEASE OF MEDICAL RECORDS
TO Alight
Specific to Americans with Disabilities Act and Request for Workplace Accommodation

Employee’s Full Name: _____________


Jeilyne Marrero Date of Birth: _______
7/29/1991

Social Security Number (last 4 digits only): xxx-xx-

Employer’s Name: _____________


SCI

Note: This form is intended to aid the employee who believes that he or she has a disability
and who wishes to request a reasonable accommodation under the Americans with
Disabilities Act (ADA), as amended, or any other applicable state law. The employee is not
required to sign this form and can still have his or her request for an accommodation
considered by returning the Accommodation Request Assessment Form, completed
and signed by the employee’s health care provider. By considering this request, the Employer
does not consider or regard the employee as having a disability as defined by the ADA or
any other applicable law.

I authorize and request all doctors, hospitals, other health care providers and facilities,
government agencies, insurers, health and benefit plan administrators or their successors
(“Records Holders”) to collect all my medical records, documents, files and/or protected
healthcare information (“Documents”) that may be in his/her custody and control and to
release those Documents to the employer named above, Alight

my employer’s benefit plan or claims administrator(s) and their related


companies, contractors, investigators, attorneys, and service consultants, health care
providers who treat or evaluate me with respect to my claim, and other individuals or
entities involved in administering, evaluating, analyzing, and managing my request
for an accommodation (collectively “Recipient”), to allow them to evaluate, analyze,
manage and/or administer my disability, physical or mental condition, or claim for leave or
accommodation on behalf of my employer. These Documents include any information related
to my disability and request for reasonable accommodation.

This Authorization may include disclosure of Documents relating to treatment for ALCOHOL,
DRUG ABUSE, HIV RELATED DOCUMENTS, and MENTAL HEALTH CARE except
psychotherapy notes, but only if I place my initials on the appropriate lines below. In the event
my Documents include any of these 5 types of Documents and I initial the line below, I
specifically authorize release of such Documents.
Alight

P.O. Box 1438 LeaveID: 328700646869


Lincolnshire IL 60069-1438 Fax: (518) 880-6904
Include in my Documents (Indicate by Initialing):

Alcohol/Drug Abuse Treatment


Mental Health Documents
Sexually Transmitted Diseases (STDs)
AIDS/ HIV-Related Documents
Recipients will tell any other Recipient to whom they may forward such Documents that the
Documents are confidential. I understand the HIPAA law requires that I be advised that
Documents released may be re-disclosed by Recipient to other parties where state and
federal privacy laws may not protect it.

The purpose of providing these Documents to the Recipients is to allow them to evaluate,
manage and/or administer my claim for a workplace accommodation, pursuant to the ADA
and any applicable state law.

Any facsimile or copy of this Authorization shall authorize the release of my Documents for
the above-stated purpose. This Authorization shall be in force and effect for one (1) year from
date of execution, at which time this Authorization expires. If I change my mind before then,
I can revoke the authorization by telling each Recipient in writing that I do not want that
Recipient to obtain any more Documents, although that will not affect any actions a
Recipient took before receiving my letter.

I understand that signing this Authorization is voluntary and that if I do not sign this form the
Recipients may result in the delay or denial of my request for accommodation.

__________________________________________________________ 12/27/2023

Signature of Claimant or Legal Representative Effective Date

_______________________________________________________
Print Name & Relationship of any Legal Representative to Claimant (i.e. attorney, legal guardian,
etc.)

THIS AUTHORIZATION FOR RELEASE OF RECORDS IS IN 14-PT FONT IN COMPLIANCE WITH


CALIFORNIA LAW AT CAL.CIV.CODE §56.11.

Alight LeaveID: 328700646869


P.O. Box 1438 Fax: (518) 880-6904
Lincolnshire IL 60069-1438
SCIC-4-328700646869
Accommodation Request Assessment Form
DATE:
REGARDING: Employee Name: Jeilyne Marrero
Employee DOB: 7/29/1991

COMPLETED FORM MUST BE RETURNED TO Alight


The above employee has requested a workplace accommodation, either because of a potential disability under the
Americans with Disabilities Act (ADA) or state anti-discrimination law, or because the employee is pregnant and
seeks an accommodation under an applicable pregnancy accommodation law. The information requested on this
form will assist us in making a determination regarding the employee’s request.

INSTRUCTIONS: The following form must be completed in detail and signed by the employee’s attending medical
provider. Please attach additional pages or records as needed. Do not provide information that is not related to
the employee’s ability to perform his/her job duties. Example: Do not identify an impairment if it does not have
an impact on the employee’s ability to perform his/her job duties. For California employees who are pregnant
without an underlying medical condition and are only seeking a workplace accommodation and not a leave of
absence, please complete only questions 1, 2, and 10. For Hawaii and Montana employees who are pregnant and
seeking either leave or a workplace accommodation, please complete only questions 1, 2, 10, and 11.

IMPORTANT: If employee is requesting a medical exemption to a COVID-19 vaccine with no other


accommodations, only provide information that is related to the impairment or condition that precludes the
employee from receiving a COVID-19 vaccine.

IMPORTANT NOTICE REGARDING GINA

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of employees or their family
members. In order to comply with this law, we are asking that you not provide any genetic information
when responding to this request for medical information from Alight

“Genetic information,” as defined by GINA, includes an individual’s family medical history, the results
of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s
family member sought or received genetic services, and genetic information of a fetus carried by an
individual or an individual’s family member or an embryo lawfully held by an individual or family
member receiving assistive reproductive services.

1. Please confirm whether you have examined the employee and are familiar with the employee’s medical
history:
X
Yes No

2. Will this employee have a need for any of the following? Check ALL that apply:
Restrictions Limitations Accommodations
X
Leave of absence COVID-19 vaccine medical exemption None of the above

Alight LeaveID: 328700646869


P.O. Box 1438
Fax: (518) 880-6904
Lincolnshire IL 60069-1438
If None of the above, please state the employee’s unrestricted return to work date:

3. Existence of impairment.
a. Does the employee have a physical or mental impairment(s)? X
Yes No
b. Is the impairment related to pregnancy or childbirth? Yes X
No
i. If yes, are there complications?
ii. If yes, describe the complications (Do not answer without patient consent in CA, ME,
or RI):_______________________________________________________________
____________________________________________________________________
iii. Estimated Delivery Date: __/__/__ Actual Delivery Date: __/__/__
4. Please list impairment(s) (Note: Some state laws may prohibit providing a diagnosis):
_____________________________________________________________________________________
F41

Note: A physical or mental impairment under the ADA is:

• Any physiological disorder, condition, cosmetic disfigurement, or anatomical loss affecting one or
more body systems, such as neurological, musculoskeletal, special sense organs, respiratory
(including speech organs), cardiovascular, reproductive, digestive, genitourinary, immune,
circulatory, hemic, lymphatic, skin, and endocrine; or

• Any mental or psychological disorder, such as an intellectual disability, organic brain syndrome,
emotional or mental illness, and specific learning disabilities.

*The definition of an impairment may differ slightly under state law.

5. COVID-19 Vaccine Exemption. Does the employee’s impairment(s) prevent the employee from receiving a
COVID-19 vaccination? Yes No X

If Yes, is the exemption:


Temporary, ending on : / /
Permanent
6. Limitations on major life activities. Does the employee’s impairment substantially limit one or more major life
activities? Yes No
X

Note: Whether an impairment substantially limits a major life activity of the employee is determined:

• As compared to most people in the general population;

• Without regard to the ameliorative effects of mitigating measures such as medication, medical
supplies or equipment, prosthetics, hearing devices, mobility devices, assistive technology,
reasonable accommodations, auxiliary aids, or behavioral or adaptive neurological
modifications; and

• When the impairment is active, for impairments that are episodic or in remission.

7. Limitations on major life activities (cont.). Which major life activity(ies) is/are substantially limited?

Alight
LeaveID: 328700646869
P.O. Box 1438
Fax: (518) 880-6904
Lincolnshire IL 60069-1438
Major life activities – general life activities:

□ Bending □ Interacting with others □ Reaching □ Standing


□ Breathing □ Learning □ Reading □X Thinking
□ Caring for self □ Lifting □ Seeing □ Walking

X
Concentrating □ Performing manual tasks □ Sitting □X
Working
□ Eating □ Sleeping □ Other(s) (describe)
□ Hearing □ Speaking

Major life activities – operation of major bodily functions:

□ Bladder □ Digestive □ Lymphatic □ Reproductive


□ Bowels □ Endocrine □ Musculoskeletal □ Respiratory
□ Brain □ Genitourinary □ Neurological □ Sensory organs & skin
□ Cardiovascular □ Hemic □ Normal cell growth □ Other(s) (describe)
□ Circulatory □ Immune □ Operation of an
organ

8. Commencement of impairment(s). For the impairments identified above, when did the employee’s
impairment(s) commence? If there is more than one impairment, please specify the start date for each:
Agosto 2023

9. Performance of essential job functions. Does the employee’s impairment(s) limit his/her ability to perform
the essential functions of the employee’s position (as defined in the job description) without any
accommodation? Yes No X

If the answer is yes, please:

a. Identify which essential function(s) the employee is unable to perform without an accommodation:

b. Describe the manner in which the employee’s ability to perform each essential function is limited:

10. Accommodation(s).

a. Please describe the workplace accommodation(s) that you are recommending for the employee (for leave
as an accommodation, please also answer question 10):

Note: Reasonable accommodations may include such things as a modified work schedule, provision of special
equipment, workplace accessibility modifications, shifting of non-essential duties of the employee’s position,
and extended leave of absence to allow time for recovery, therapy, training, or other disability-related needs.

Alight
P.O. Box 1438 LeaveID: 328700646869
Lincolnshire IL 60069-1438 Fax: (518) 880-6904
Reasonable accommodations related to the COVID-19 vaccine might include an exemption to receiving the
vaccine and/or such things as regular COVID-19 testing, required masking, socially distanced workspace,
modified work schedule, etc.

b. If the accommodation is to assist with a physical limitation, please complete the attached Appendix A,
Physical Capacity Assessment form. (not required if requesting only a COVID-19 vaccine exemption)
c. How will the accommodation(s) assist the employee in performing the essential job functions?

d. Duration. For how long do you anticipate the employee will need the identified accommodation(s)?

Start date: / / End date: / / or permanent


For multiple accommodations, please list each accommodation’s duration separately: ____________
___________________________________________________________________________________

NOTE: You must provide your best medical judgment, based on current information, as to the length of time
the employee will need an accommodation to perform his/her essential job functions.

11. Is this employee specifically requesting a leave of absence as an accommodation? Yes X


No

Note: If Yes, answer part the remaining sections of question 10 (a, b, and c) below. If No, skip the rest of
Question 10 and proceed to Question 11.

a. Will leave assist the employee in eventually returning to work? Yes No

b. How will leave assist the employee in returning to work?

c. Duration and Type of Leave. Please indicate the type of leave needed and complete the duration details
for that section.

X
CONTINUOUS LEAVE:
If the employee requires leave for a single continuous period of time, please complete this section.
Start date of leave: 12/27/2023
/ / End date of leave: / /
01/22/2024

IMPORTANT: An end date must be provided. “To be determined,” “unknown,” or “indefinite” is not adequate. If you
are unsure of the end date, provide your best estimate. End dates can be changed, if necessary, with updated
documentation.
REDUCED LEAVE:
If it is medically necessary due to the patient’s condition for the employee to reduce the number of
hours of the employee’s daily or weekly work schedule, please complete this section.
• Start date of leave: / / End date of leave: / /
• Reduced Schedule: ___ days per week ___ hours per day and/or week
INTERMITTENT LEAVE:
If it is medically necessary due to the patient’s condition, for the employee to take leave in intermittent
periods of time, please complete this section.
ii. Incapacity (Estimated Episodic Flare-Ups):

Alight
LeaveID: 328700646869
P.O. Box 1438
Fax: (518) 880-6904
Lincolnshire IL 60069-1438
• Start date: / / End date: / /
• Episodes will be times every days (use 7, 30, 365). Each episode of incapacity
may last up to hours or days. (e.g., 2 times every 30 days, lasting up to 1 day)
iii. Office Visits and/or Treatment Schedule (Excluding Incapacity Time):
• Start date: / / End date: / /
• Office visits and/or treatments will be time(s) every days (use 7, 30, 365).
• Each office visit and/or treatment will last approximately hours. (e.g., 2 times
every 30 days, lasting up to 2 hours)

NOTE: You must provide your best medical judgment, based on current information, as to the length of time the
employee will need an accommodation to perform his/her essential job functions.

12. Additional information. Are you aware of any other information that should be considered in assessing
whether the employee can perform the essential job functions with or without accommodation?
Yes No
X

If yes, please describe:

Provider Name (print): Dr. Giovanni Alomar Sastre

Provider Signature:

Provider Practice/Specialty: Psicólogo Clínico

Provider Phone Number: 939-835-7173

Provider Fax Number: _________

Provider Address: 3020 Ave San Cristobal, Coto Laurel PR 00780-2896

Provider Email: ___________________________________________________________


dr.giovannialomar@gmail.com

Date: 17/Enero/2024

Alight LeaveID: 328700646869


P.O. Box 1438 Fax: (518) 880-6904
Lincolnshire IL 60069-1438
SCIC-1-328700646869
Appendix A: PHYSICAL CAPACITY ASSESSMENT FORM

PATIENT NAME: Jeilyne Marrero

EMPLOYER: SCI

A. In a workday, patient can:

Activity Never 1-2 hours 2-4 hours 4-6 hours 6-8 hours 8-10 hours 10-12 hours
Sit
Stand
Walk
Drive

B. Check the maximum limit and frequency that the patient can:

Activity 0 – 10 lbs 11 - 24 lbs 25 – 34 lbs 35 – 50 lbs 51 - 74 lbs 75 – 100 lbs


Lift
Not at All (0%)
Occasionally (1% - 33%)
Frequently (34% - 66%)
Continuously (67% -
100%)
Carry
Not at All (0%)
Occasionally (1% - 33%)
Frequently (34% - 66%)
Continuously (67% -
100%)
Push/Pull
Not at All (0%)
Occasionally (1% - 33%)
Frequently (34% - 66%)
Continuously (67% -
100%)

C. Check the frequency that the patient could:

Frequency Bend/Stoop Squat Kneel Crawl Climb Balance Twist Reach


Not at All (0%)
Occasionally (1% - 33%)
Frequently (34% - 66%)
Continuously (67% - 100%)

D. Indicate the patient’s capacity to use the hand for repetitive physical tasks:

Activity: Please Circle Simple Grasping Firm Grasping Fine Manipulation Pushing/Pulling
Right Hand Yes No Yes No Yes No Yes No
Left Hand Yes No Yes No Yes No Yes No

Alight

P.O. Box 1438 LeaveID: 328700646869


Lincolnshire IL 60069-1438 Fax: (518) 880-6904
Appendix A: PHYSICAL CAPACITY ASSESSMENT FORM

PATIENT NAME: Jeilyne Marrero

EMPLOYER: SCI

E. Indicate the patient’s capacity to use feet for repetitive movements as in operating foot controls:

Right Foot Left Foot Both Feet


Yes No Yes No Yes No

F. Does the patient have any difficulties with:

Talking Hearing Smelling/Tasting Vision


Yes No Yes No Yes No Yes No

Please explain: _________________________________________________________________________________________

________________________________________________________________________________________________________

G. Does the patient have any restrictions of activities involving:

Exposure to cold, heat, wet or humidity


Noise (please include dB limit)
Vibration
Exposure to fumes, odors, chemicals, gases or dust
Moving mechanical parts
Unprotected heights
Operating equipment

Please explain: ___________________________________________________________________________________

_____________________________________________________________________________________________________

H. Is the patient taking medications that may affect their ability to work? Yes No

If Yes, please explain the work limitations as a result of taking the medication:
_____________________________________________________________________________________________

_______________________________________________________________________________________________________

I. Please check the exact degree of work you feel the patient is able to perform:

Sedentary Work - Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of
force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human
body. Sedentary Work involves sitting most of the time, but may involve walking or standing for brief
periods of time. Jobs are sedentary if walking and standing are required only occasionally and other
sedentary criteria are met.
Light Work - Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of
force frequently, and/or negligible amount of force constantly to move objects. Physical demand

Alight

P.O. Box 1438 LeaveID: 328700646869


Lincolnshire IL 60069-1438 Fax: (518) 880-6904
Appendix A: PHYSICAL CAPACITY ASSESSMENT FORM

PATIENT NAME: Jeilyne Marrero

EMPLOYER: SCI

requirements are in excess of those for Sedentary Work. Light Work usually requires walking or
standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of
forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light
Work.
Medium Work - Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3
kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.
Heavy Work - Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7
kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.
Very Heavy Work - Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of
50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to
move objects.

Physician’s Name: ______________________________________________________

Physician’s Signature: ___________________________________________________

Date: _________________________

Alight

P.O. Box 1438 LeaveID: 328700646869


Lincolnshire IL 60069-1438 Fax: (518) 880-6904
Appendix A: PHYSICAL CAPACITY ASSESSMENT FORM

PATIENT NAME: Jeilyne Marrero

EMPLOYER: SCI

Alight LeaveID: 328700646869


P.O. Box 1438 Fax: (518) 880-6904
Lincolnshire IL 60069-1438
SCIC-44-328700646869
Employee’s Essential Job Functions Form
To Be Completed by Supervisor or Human Resources and returned to Alight

Please Note: Your employee has requested a workplace accommodation. As such the following information will
establish the essential functions of the job to help determine whether the accommodation will enable the
employee to perform those essential job functions.

Employee Name: Jeilyne Marrero


Absence ID: 328700646869

An Essential Job Function must meet at least one of the following criteria:
1. The reason the position exists is to perform this duty. Removing this function would fundamentally change
the position.
2. A limited number of employees are available to do the function.
3. The person must have expertise to perform this duty.

Position Name:

Job Description: (please send or write short summary)

Is the above job description for this employee accurate and complete? If not, please add any additional job
functions or make clarifications below, mark only the areas that apply.

Are there any additional minimum qualifications and/or competencies of the position that were not in the job
description?

Equipment Use (mark only what applies) Rarely 1 – 15% Occasionally 16 – 45% Frequently 46 - 100%
Telephone
Computer
Copier
Fax Machine
Use of Vibrating Machinery
Operate Machinery
Keyboard
Mouse
Other (please add):

Physical Demands (mark only what applies) Rarely 1 – 15% Occasionally 16 – 45% Frequently 46 - 100%
Bend/Stoop/Crouch
Lifting up to ______ lbs
Performing Manual Tasks
Reach at Shoulder Level
Reach Above Shoulder Level
Reading
Seeing
Sitting
Speaking

Alight
LeaveID: 328700646869
P.O. Box 1438
Fax: (518) 880-6904
Lincolnshire IL 60069-1438
Physical Demands cont. Rarely 1 – 15% Occasionally 16 – 45% Frequently 46 - 100%
Standing
Walking
Walking on Uneven Ground
Pulling
Driving (for work)
Push/Pulling
Kneeling
Climbing
Crawling
Stooping
Twisting
Balance
Use of Hands Repetitively

Hand Use: Power Grasp/Grip/ Turn


Other: (please add)

Mental Demands (mark only what applies) Rarely 1 – 15% Occasionally 16 – 45% Frequently 46 - 100%
Problem Solve
Make Decisions
Supervise
Interpret Data
Organize
Write
Plan
Concentrating
Other: (please add)

Working Conditions (mark only what applies) Rarely 1 – 15% Occasionally 16 – 45% Frequently 46 - 100%
Indoor
Outdoor
Hot Temperatures
Cold Temperatures
Loud Noise
Fumes
Exposure to VDT Screens
Work At Heights
Other: (please add)

Alight LeaveID: 328700646869

P.O. Box 1438 Fax: (518) 880-6904

Lincolnshire IL 60069-1438 SCIC-22-328700646869


Your Employee Rights
Under the Family and
Medical Leave Act
What is FMLA leave? You do not have to share a medical diagnosis but must provide enough
information to your employer so they can determine whether the leave
qualifies for FMLA protection. You must also inform your employer if
The Family and Medical Leave Act (FMLA) is a federal law that provides FMLA leave was previously taken or approved for the same reason
eligible employees with job-protected leave for qualifying family and when requesting additional leave.
medical reasons. The U.S. Department of Labor’s Wage and Hour Division
(WHD) enforces the FMLA for most employees. Your employer may request certification from a health care provider
to verify medical leave and may request certification of a qualifying
Eligible employees can take up to 12 workweeks of FMLA leave exigency.
in a 12-month period for:
The FMLA does not affect any federal or state law prohibiting
• The birth, adoption or foster placement of a child with you,
discrimination or supersede any state or local law or collective bargaining
• Your serious mental or physical health condition that makes you agreement that provides greater family or medical leave rights.
unable to work,
State employees may be subject to certain limitations in pursuit of direct
• To care for your spouse, child or parent with a serious mental or
lawsuits regarding leave for their own serious health conditions. Most
physical health condition, and
federal and certain congressional employees are also covered by the
• Certain qualifying reasons related to the foreign deployment of your law but are subject to the jurisdiction of the U.S. Office of Personnel
spouse, child or parent who is a military servicemember. Management or Congress.
An eligible employee who is the spouse, child, parent or next of kin of a

What does my
covered servicemember with a serious injury or illness may take up to
26 workweeks of FMLA leave in a single 12-month period to care for the

employer need to do?


servicemember.

You have the right to use FMLA leave in one block of time. When it is
medically necessary or otherwise permitted, you may take FMLA leave
intermittently in separate blocks of time, or on a reduced schedule by If you are eligible for FMLA leave, your employer must:
working less hours each day or week. Read Fact Sheet #28M(c) for more • Allow you to take job-protected time off work for a qualifying reason,
information.
• Continue your group health plan coverage while you are on leave on
FMLA leave is not paid leave, but you may choose, or be required by your the same basis as if you had not taken leave, and
employer, to use any employer-provided paid leave if your employer’s • Allow you to return to the same job, or a virtually identical job with
paid leave policy covers the reason for which you need FMLA leave. the same pay, benefits and other working conditions, including shift
and location, at the end of your leave.

Am I eligible to take Your employer cannot interfere with your FMLA rights or threaten or
punish you for exercising your rights under the law. For example, your

FMLA leave?
employer cannot retaliate against you for requesting FMLA leave or
cooperating with a WHD investigation.

You are an eligible employee if all of the following apply: After becoming aware that your need for leave is for a reason that may
qualify under the FMLA, your employer must confirm whether you are
• You work for a covered employer, eligible or not eligible for FMLA leave. If your employer determines that
• You have worked for your employer at least 12 months, you are eligible, your employer must notify you in writing:
• You have at least 1,250 hours of service for your employer during • About your FMLA rights and responsibilities, and
the 12 months before your leave, and • How much of your requested leave, if any, will be FMLA-protected
• Your employer has at least 50 employees within 75 miles leave.
of your work location.

Airline flight crew employees have different “hours of service”


requirements. Where can I find more
You work for a covered employer if one of the following applies:
• You work for a private employer that had at least 50 employees during
information?
at least 20 workweeks in the current or previous calendar year, Call 1-866-487-9243 or visit dol.gov/fmla to learn more.
• You work for an elementary or public or private secondary school, or
If you believe your rights under the FMLA have been violated, you may
• You work for a public agency, such as a local, state or federal file a complaint with WHD or file a private lawsuit against your employer
government agency. Most federal employees are covered by Title II in court. Scan the QR code to learn about our WHD complaint process.
of the FMLA, administered by the Office of Personnel Management.

How do I request scan me


FMLA leave?
Generally, to request FMLA leave you must:
• Follow your employer’s normal policies for requesting leave,
• Give notice at least 30 days before your need for FMLA leave, or WAGE AND HOUR DIVISION
• If advance notice is not possible, give notice as soon as possible. UNITED STATES DEPARTMENT OF LABOR

SCIC-47-328700646869

WH1420 REV 04/23


LeavePro

Save Time. Go Online.

Welcome to LeavePro
It’s Fast, Easy & Online
You can view and manage your leave from a computer, tablet or mobile device with LeavePro. Save time
by going online to quickly address your basic leave needs.

Available 24/7, simply log in via the internet: https://sci.myleaveproservice.com

More Features to Better Manage Your Leave


With LeavePro, you can more efficiently manage your leave online at your convenience. Intuitive,
streamlined navigation helps you quickly find leave information or complete leave tasks. It’s all at your
fingertips – no need to call to complete these actions. You can:
• Easily submit a new leave, manage a current leave, and view details of all leaves
• Quickly view and complete your required tasks to keep leave request moving forward
• Receive alerts and notifications, via text and/or email, to keep informed of leave status
• Securely upload documents via computer or mobile device; please have all documentation ready
to upload at one time
• View leave status and remaining time available
• Add time-off request to an intermittent leave; reporting must be completed as outlined in your
employer’s internal leave policy
• View and confirm expected date for returning to work

Mobile Home Page Desktop Home Page

SCIC-48-328700646869
Frequently Asked Questions (FAQ)
What happens to my Health and Welfare Benefits while I’m out?

If your claim is for STD, FMLA, and/or applicable state leave, or personal and you are enrolled in the
Company’s group insurance program (health, dental, vision, life, etc.), you will be billed directly by
WEX Health. You will have a 30-day grace period to make the premium payments. Failure to make a timely
payment will result in cancellation of coverage.

If your claim is for Military and you are enrolled in the Company’s group insurance program (health,
dental, vision, life, etc.), you will have the option to continue coverage under COBRA.

The Company will continue to pay its portion of the premiums during your leave. If you fail to return to
work for any reason other than: (1) the continuation, recurrence or onset of another serious health
condition which would entitle you to FMLA leave; or (2) other circumstances beyond your control, you
may be required to reimburse the Company for their share of any insurance premiums paid on your behalf
during your leave. If you remain out on leave of absence for more than 180 days, your benefits will be
cancelled at the end of the month and you will be offered COBRA from WEX.
Questions about your eligibility or account status should be directed to WEX Health at
1.866.451.3399.
What happens to my 401(k) while I’m out?

While on “unpaid leave”, you will not have sufficient regular earnings via your paycheck to cover your loan
repayment. You MUST contact Charles Schwab retirement “plan” to request a loan repayment suspension.
Charles Schwab may grant a loan repayment suspension to help avoid a default on your loan.

When unpaid leave ends, the loan must be repaid. The plan may refinance your loan over the remaining
period of the original loan (which will increase your original payment amount.) Your other option is to pay
off your loan before you begin your leave of absence. Charles Schwab cannot extend your payment period
beyond the original payoff date.

Employees on military leave will be permitted to refinance their loan over a period of remaining life of the
loan (upon return), plus the period of military service. Charles Schwab Participant Services can be
contacted at 800‐724‐7526.
What do I do when I am ready to return to work?

If you have taken a medical leave, before you can return to work, you must submit documentation from
your health care provider certifying that you are able to return to work to your Manager and the Benefit
Resource Center. A Return-to-Work or Fit-for-Duty Certification form can be obtained by contacting Alight at
1.866.451.3399.

If you have taken a military leave, prior to returning to work, reach out to your Manager and the SCI Leave
& Disability Team.

If you have taken an Educational or Mortuary School leave, prior to returning to work, reach out to your
Manager and the SCI Leave & Disability Team. Additionally, when you are returning from an educational
leave, you will need to present the Company with sufficient proof of completion prior to reinstatement.
The proof must certify that you attended an accredited college or university on a full-time basis and
successfully completed courses intended for career development. A diploma, transcript, or letter of
certification are acceptable forms of documentation. Documents can be emailed to
benefitservice.center@sci-us.com or faxed to (504) 729-1813.

What about Paid Maternity Leave (PML)?

SCI will provide Paid Maternity Leave (PML) if you are a Regular full-time female associate with at least
one year of continuous employment (at least six months of which have been on a full-time basis) who are
giving birth, are eligible to receive a maximum of six (6) weeks of concurrent Paid Maternity Leave (PML),
at their full salary or hourly rate (excluding commissions, bonuses or other ancillary compensation),
running concurrently with their FMLA leave, if applicable. Upon exhaustion of the six weeks of PML, you
may use any accrued unused sick and vacation time concurrently with the balance of any FMLA leave.
PML must be taken as one consecutive leave and generally commences following the birth of a child.
However, when deemed medically necessary, it may commence earlier. SCI Company complies with all
applicable federal, state and local laws. If any portion of this policy conflicts with any applicable laws, then
the laws will supersede the Company’s policy in those specific locations. In the event that you have
exhausted PML, and you encounter complications relating to the birth, you may be eligible for additional
disability benefits for the duration of the medical complication(s). If you have additional questions, call
the Benefits Resource Center at 1.844.431.4357, Select Option #1 and then Option #2.

How do I add my child to my healthcare insurance?

You have 31 days from the birth of the child(ren) to contact the Benefit Resource Center. Please contact
the Benefits Resource Center at 1.844.431.4357 or benefitservice.center@sci-us.com to add your child
to health insurance coverage.
What is Paid Baby Bonding?

SCI provides benefits-eligible, non-union, mothers and fathers up to two weeks of paid time off to bond
with a new child. In order to be eligible for this benefit you must have one year of continuous employment
prior to the birth, adoption or foster care placement. The use of this time off benefit must be completed
within one year of the birth, adoption or placement.

For information regarding Paid Baby Bonding contact the Benefits Resource Center at 1.844.431.4357,
option 2, then 1.

What is Paid Military?

SCI provides benefits-eligible, non-union, associates up to three weeks of paid time off (based on military
orders) to participate in Annual Training (AT). In order to be eligible for this benefit you must have one
year of continuous employment prior to the Annual Training. Eligible associates will receive 100% of their
base pay for up to a maximum of three weeks in a calendar year. This pay will be in addition to any
compensation received from the military.

For information regarding Paid Military contact the Benefits Resource Center at 1.844.431.4357, option
2, then 1.

What if your spouse works for the same company?


If both spouses are employed by the company, the combined leave under federal and/or state FML laws
for birth, newborn care and/or adoption or foster care placement, or care for the employee’s parent with
a serious health condition, shall not exceed 12 weeks.

The combined leave for spouses working for the company is limited to 26 weeks to care for a family
military member with a serious illness or injury incurred while on active duty, or when the 26 week FMLA
military leave entitlement is taken in combination with leave for either birth, newborn care and/or
adoption or foster care placement, or to care for the employee’s parent with a serious health condition.
Each employee may use the remainder of his or her individual leave under federal and/or state FML laws
for their own serious health condition, or due to a qualifying exigency relating to a family member’s call
to active military duty.
Enclosed you will find a married couple information form to determine if this limitation may apply to your
leave. You need to review and complete the information as outlined on the form, and return with any
other required certification forms within 15 calendar days of the date of this letter.

What about your Paid Time Off (PTO)?

FMLA and/or applicable state leave is unpaid time off. You are required to use any accrued sick time
concurrently with any unpaid portion of your FMLA leave. You can also elect to use any accrued
unused vacation to cover all or part of the unpaid portion of your leave. If you do not have enough
accrued sick and/or vacation time to cover your entire leave, the portion that is not covered will be
unpaid leave.
SCIC-660-328700646869

You might also like