[COMPANY]

LETTER TO EMPLOYEE: FMLA LEAVE FOR QUALIFYING EXIGENCY

Date:

Dear [employee name]:

[The Company] ______received notification that you have requested Military Family Leave (FMLA) because of a qualifying exigency of a family member effective _____ [date]. Effective the date of this letter, we are provisionally placing you on FMLA leave.

You are entitled to up to twelve (12) weeks of FMLA in a 12-month period. You previously have used ______[days/hours] of FMLA during the current 12-month period and thus the total remaining FMLA available to you is ______[days/hours].

According to the information we received, you may be able to return to work on ______[date]. If, for any reason, you are unable to return to work, you must notify ______at (___)____-_____ [Company] prior to the return date. If you fail to return to work at the end of the approved FMLAleave, we will not guarantee reinstatement to your previous position or any other position.

While on FMLAleave, your health benefits will continue for a maximum of twelve (12) weeks. If you currently contribute to the payment of benefits, you must continue to do so while on leave, beginning on ______[date]. The amount of each payment is $______and must be paid to the Company. The payments will be due on or before the ____ [day] of each month. Your coverage will end on ______if you do not return to work,at which time you will be eligible for COBRA. Information pertaining to COBRA will be sent to you at that time.

While on your FMLA leave you will be responsible for contacting ______at ______to make arrangements to continue to make your share of the health insurance premiums in order to maintain health benefits while you are on leave. You have a 30-day grace period in which to make premium payments. If payment is not made on time, your group health insurance may be cancelled, provided we notify you in writing at least 15 days before the date your health coverage will lapse, or, at our option, we may pay your share of the premiums during your FMLA leave and recover these payments from you upon your return to work. 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; 2) the continuation, recurrence, or onset of a covered service member’s serious injury or illness which would entitle you to FMLA leave; or 3) other circumstances beyond your control, you may be required to reimburse us for our share of the health insurance premiums paid on your behalf during your leave

Further, this leave will be considered protected under FMLA, and the leave will be counted against your FMLA leave entitlement. You have the right to reinstatement to the same position, or an equivalent position in terms of pay, benefits, and terms and conditions of employment, upon your return from FMLA leave. If your leave extends beyond the end of your FMLAentitlement, you may not have reinstatement rights under these statutes.

You will find enclosed a Certification of Qualifying Exigency for Military Family Leaveform. Please return this form to [Company] on or before ______[insert date, allow 15 days]. After receipt and review of this form, we will make a determination on the designation of your absence as FMLAleave.

Please contact ______at (___)___-____if you have any questions or would like any more information regarding FMLAleave or this information. We wish you the best and look forward to your return.

Sincerely,

______

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