GSD employee’s must always be on an approved leave. Listed below in alphabetical order are the necessary forms an employee may need for a leave option. Please complete the necessary forms and return to the benefits office.
Allstate Claim Forms
Listed below are the forms you will need to file claims with Allstate. The Outpatient form you will use to submit a claim for seeing a physician.
Beneficiary Change Form
Beneficiary is the person/persons you want to leave any life insurance or other financial payouts too in the unlikely event of your death. Use this form to make changes to your beneficiary.
Diagnosis Functional & Limitations Form (DFL)
Use this form if you are gone for more than 3 consecutive days for sick leave (other than typical cold/flu). Anytime you have surgery or have other medical related issues you will need the DFL form prior to leaving, and prior to returning. The DFL form is required releasing you back to work. The DFL form is also required as part of the short term disability leave.
– DFL Form
Evidence Of Insurability (EOI)
If you make an election/change to your life insurance or long term disability after your guaranteed issued opportunity. You will need to complete the EOI form which is a health questionnaire your doctor must complete. You will then submit that form back to the carrier. Your benefit election/change will only be affective once your EOI is approved by the carrier.
Family Medical Leave Act (FMLA)
Eligible employees can take up to 12 work weeks of unpaid leave during any 12-month period to attend to the serious health condition of the employee, parent, spouse or child, or for pregnancy or care of a newborn child, or for adoption or foster care of a child. In order to be eligible for FMLA leave, an employee must have been employed at least 12 months, and worked at least 1,200 hours over the past 12 months. For more information on FMLA leave please click here.
– FMLA APPLICATION 7-16
– FMLA MEDICAL FORM-EMPLOYEE
– FMLA MEDICAL FORM-FAMILY MEMBER
Flexible Spending Reimbursement
Use the form when you need to submit receipts for your Flexible Spending Account(FSA).
– FSA Claim Reimbursement Form
Life Status Change Form
Anytime you have a life changing event for example: marriage, death, divorce, birth of child, adoption, loss of benefit coverage, FTE status change. You have 30 days from the date of the qualifying event to make changes to your benefit insurance. This form is what you will complete and turn into the benefits office along with proper documentation of life event.
Life Insurance Termination Continuation Forms
Employees are able to continue life insurance coverage when they terminate. Employees have 30 days from the date of termination to convert their group life insurance policy into their own private policy. There are two ways this can be done. 1) Conversation – This form is used to convert your group life insurance into your own personal policy. New rates would apply. 2) Portability – This form is used to convert your group life insurance into your own personal policy and maintain the rates you are currently paying. If the District ever changed life insurance carrier you would lose your portability coverage.
– Life Insurance Conversation Form
– Life Insurance Portability Form
Maternity
Taking time off for maternity varies for each individual employee. This document hopefully will help answer your questions when it comes to your maternity leave.
Short Term Disability (STD)
Eligible employees can take up to 120 calendar days earning 80% of their daily rate. STD can only be used for employees own health condition. For more information on STD leave and eligibility please click here.