Employee Leave of Absence Request

Guidewire, Inc

EMPLOYEE LEAVE OF ABSENCE REQUEST

Approval Process:

1.  Print clearly and make sure all fields are complete.

2.  Submit the written request to your Manager two weeks in advance, when at all possible.

3.  Manager reviews information, signs and submits to Program Director

4.  Program Director reviews and submits to the Vice President for approval.

5.  Employee will be notified by Human Resources of the decision in the mail.

6.  Returning from leave: An employee shall be returned to the same or a substantially equivalent position unless such position no longer exists; or, unless a separate lawful reason exists.

Leave of Absence information: If the employee is taking more unpaid time off than one week, he/she must apply for a leave of absence or family medical leave. (See handbook for full leave policy and call Human Resources with questions about Leave of Absences)

(ALL FIELDS MUST BE COMPLETED BY EMPLOYEE)

Today’s Date ______Leave Start Date: ______Return to Work Date: ______

Employee Name: ______Phone number(s): ______

Current Address: ______

Current Site(s) # ______Supervisor Name(s): ______

Employees Reason for leave: ______

______

Contact Information while on leave: ______

______

Employee Signature: ______DATE: ______

FOR MANAGER ONLY: Request has been reviewed and employee section of form is complete.

Print Name: ______Signature: ______Date:______

FOR PROGRAM DIRECTOR ONLY:

Vacation Remaining ____ Personal Remaining ____ Vested Remaining ____

This request has been reviewed.

Print Name: ______Signature: ______Date: ______

FOR OFFICE USE ONLY: VP of the department in conjunction with HR will approve/disapprove request.

Approved Not Approved Missing information______

Dept VP Print Name: ______Sign: ______Date______

HR Print Name: ______Sign: ______Date ______

FOR HUMAN RESOURCES USE ONLY:

______emailed decision TO: PMs listed above; CC: all PDs, HR and VP on______

(Initial) (Date)

______mailed copy of this decision to employee address provided above on ______

(Initial) (Date)

(Completed original to be kept in employee file)