This form is to be fully completed and signed by the individual making the request without disclosing private personal health information LEAVE OF ABSENCE REQUEST

Employee Name:

Personal Email:

Personal Phone:

Job Schedule (check one): Full Time Part Time

EMPLOYEE INFORMATION

LEAVE OF ABSENCE REQUEST REASON

LEAVE OF ABSENCE REQUEST SCHEDULE

PURPOSE OF LEAVE REQUEST: Reason for your request for job-protected leave of absence time must be noted below for request to be considered. Medical for My Own Serious Health Condition You must sign and date the medical leave authorization included. Care for a Family Member with A Serious Health Condition Information below is required and may impact eligibility for leave of absence. Relationship to Family Member: Family Member Name: Family Member Date of Birth: Family Member’s State of Residency: Pregnancy / Childbirth Employee is personally experiencing pregnancy disability. Information below required. Expected Delivery Date:

Check this box if you also intend to request baby bonding time following pregnancy disability period, if eligible for this time away. Baby Bonding Employee is not personally experiencing pregnancy disability. Information below required. Expected Date Of Birth: Actual Date of Birth: Adoption/Foster Date of Placement: Military Leave of Absence Information below required. Active Duty Self Caring for Injured Servicemember Family Member Active Duty / Deployed Military Training Other

Personal ** Non-Medical related; Reason Required **Supervisor Name & Signature Required for Personal Leaves Only** Name:

Signature:

LEAVE PERIOD

Expected Start Date:

If you are unsure, you may note your

best estimated start date.

Expected Return Date:

If you are unsure, you may note your

best estimated return date.

SCHEDULE TYPE

Please return completed form to the OneDigital Resource Center at ad2aks@r.postjobfree.com or via fax 949-***-****

*If requesting a leave of absence for Pregnancy/

Childbirth only, check this box if you intend to take full amount of eligible time away including any

eligible time available for baby bonding.

Continuous (e.g. 3 weeks of continuous time away from work) Intermittent (e.g. 1 day per week). Note: Minimum of 2 hour increments of intermittent time. Minimum of 1 day increments when used for baby bonding intermittent time. I am requesting:

This form is to be fully completed and signed by the individual making the request. LEAVE OF ABSENCE REQUEST (CONTINUED)

EMPLOYEE ACKNOWLEDGEMENT

I verify that the information included in this leave of absence request is true and accurate to the best of my knowledge. In addition to providing this information, by my signature below, I acknowledge that I understand that my company expects that I will not perform work while on an approved leave of absence. I understand that any misrepresentation on this information provided may be cause for corrective action, up to and including termination.

EMPLOYEE SIGNATURE DATE

WAGE REPLACEMENT - PAY OPTIONS DURING AN APPROVED LEAVE OF ABSENCE During a leave of absence the permission to be out of work is separate from the pay or partial pay that may be available while you are away. Your leave specialist will include information on the wage replacement options that may be available to you based on your specific situation. Please note except where otherwise required by law, performance evaluations, bonuses and merit increases, where applicable, will resume when employee re- turns to work.

By signing this agreement with my signature below I acknowledge and agree to the following:

• I am required to utilize available accrued time off (PTO, vacation time, sick time, etc.) as a form of pay or partial pay during an approved leave of absence. This is a great tool to use to cover benefit premiums or just to receive pay during your time away. I may request use my PTO by ac- cessing my timekeeping system or reaching my employer’s payroll department.

• If applicable, I may choose to apply for outside wage replacement benefits from the state or otherwise to help supplement my wages during my absence.

• If all available accrued time is exhausted and no alternative wage replacement options are available, any remaining approved time away will be taken as unpaid.

For further information about other wage replacement options that may be available to you please refer to your eligibility notice. BENEFIT PREMIUM AGREEMENT

Your benefit premiums will continue to be deducted normally from any available wages that you receive while on a leave of absence. A missed ben- efit premium is defined as a pay cycle in which you did not receive enough wages and as a result, the employee portion of these benefit premiums was not able to be deducted as originally agreed.

By signing this agreement with my signature below I acknowledge and agree to the following:

• I am required to pay the agreed upon portion of my benefit premiums in order to continue my participation under the benefit plan(s) that I am currently enrolled in during any period of a leave of absence.

• Should I have questions regarding benefits, access to my benefits system, or payment of benefits, I understand it is my responsibility to reach my employer.

• For general benefit questions and to keep up with benefit premium payments I may reach Renuka Doshi at ad2aks@r.postjobfree.com to make arrangements to ensure MSI is paid by the first of the month.

• Should I experience a qualified life event (i.e. birth of a baby) during my leave of absence, I must make the necessary changes to my benefit plans within 30 calendar days of the event date in my HRIS system, ADP.

• HRIS System Link: workforcenow.adp.com

• I understand that if I do not return to work after my leave of absence, I am responsible for reimbursing my company for all unpaid healthcare premiums and, unless certain circumstances apply, all of the company’s share of healthcare premiums paid during my leave and I agree to do so upon request by the company.

Please return completed form to the OneDigital Resource Center at ad2aks@r.postjobfree.com or via fax 949-***-****

• I understand it is my responsibility to ensure payment of my benefit premiums due. I may send a personal check by the first of each month to MSI or pre-pay MSI in advance by contacting MSI payroll. So long as employee portion of benefit payments are being made, MSI may allow me to remain on company benefits up to exhaustion of legal federal and state leave entitlement exhaustion only. Again, if I have questions, I am encouraged to reach Renuka Doshi at ad2aks@r.postjobfree.com This form is to be signed by the individual requesting a medically related leave of absence. MEDICAL LEAVE AUTHORIZATION

Authorization for Release of Information (HIPAA Release) I am requesting a leave of absence that has to do with my own medical condition, injury or illness: YES (if yes, please read and sign below) NO (if no, you are not required to sign this portion) HIPAA Release for OneDigital Resource Center

I hereby authorize any physician, nurse, or other health care professional who has attended or provided medical treatment to me, or any hospital at which I have received treatment to furnish the OneDigital Resource Center on behalf of my employer, or an authorized repre- sentative of same, any and all pertinent information relating to my request for leave and/or Short-Term Disability claim application based on my health condition. I understand that any information OneDigital Resource Center, acting on behalf of my employer, obtains pursuant to this will be used only for evaluating and administering my claim under the federal, state leave entitlements such as Family Medical Leave Act (FMLA) and or the American Disabilities Act (ADA) and which may include assistance in returning to work. I under- stand this information may be used by OneDigital Resource Center acting on behalf of my employer, to clarify and authenticate any medi- cal information presented on my medical documentation and to facilitate my short-term disability claim, if applicable. I further understand that the information OneDigital Resource Center obtains pursuant to this authorization is subject to re-disclosure for determination of re- quested benefits, which may not be protected by Federal privacy regulations. The purpose of this authorization is for OneDigital Resource Center to properly review my leave of absence request and/or ongoing eligi- bility status relative to my request for leave and/or to facilitate my short-term disability claim, if applicable. This authorization will expire one year from the date of the signature below or once I have returned from leave, whichever is later. A photocopy or faxed copy of this signed authorization shall constitute a valid authorization. EMPLOYEE NAME

EMPLOYEE SIGNATURE DATE

NOTE: The regulations permit an employer to deny a leave request if the team member refuses to execute an authorization. The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or re- quiring genetic information of an Individual or family member of the Individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘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. Please return completed form to the OneDigital Resource Center at ad2aks@r.postjobfree.com or via fax 949-***-****

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