Free Sample Leave Of Absense Without Pay Policy
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Sample Leave Of Absense Without Pay Policy

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Leave Of Absence Without Pay


To establish a procedure for requesting and approving of Leaves of Absence without pay.


State and Federal laws regarding leaves.

Employer ABC Policy for administration of Family Leaves.


Leave of Absence is approved time away from work for which the employee is not paid.

Medical leave is a Leave of Absence without pay where an employee is unable to work due to a medical illness or injury.

Personal leave is a Leave of Absence without pay where an employee is not working for personal reasons.

Family and Illness Leave is time away from work following the birth or adoption of a child, to care for a spouse, child or parent with a serious health condition, or for the serious health condition of the employee, and may include a medical leave or a personal leave.

Serious health condition is an illness, injury, and impairment or physical or mental condition requiring either inpatient treatment at a hospital, hospice or residential care facility or continuing treatment or supervision by a health care provider.


The employee shall request a Leave of Absence in advance.

·         If an employee is unable to prepare a request due to emergency, the employee's supervisor will make every reasonable effort to help employee complete the form.

Before a Leave of Absence is granted, an employee shall exhaust all usable leave balances.

New employees with insufficient service to use earned vacation leave shall obtain approval to use accrued balances prior to requesting a Leave of Absence.

The insurance benefits of an employee on a Leave of Absence will continue to be paid by the Employer.

For a Family and Illness Leave of Absence, health insurance premiums will be paid by the Employer for the first 12 weeks of "Family and Illness Leave" per year:

·         Time spent on paid "Family and Illness Leave" counts as part of the 12 weeks.

·         All other insurance benefits may be continued if the employee pays the premium for the coverage levels.

·         When a Family and Illness Leave extends beyond 12 weeks, the employee will need to pay the premiums to continue coverage past the first day of the following month.

When a Leave of Absence is not a 12 week "Family and Illness Leave", all insurance benefits shall cease on the last day of the month the leave begins:

·         If the employee continues insurance benefits, the monthly premiums shall be pre-paid by the employee.

·         If the does not to continue the insurance benefits, the waiting periods that apply to new employees shall apply when the Leave of Absence ends.

An employee cannot return to work and then commence another unpaid leave of absence in order to have that month’s insurance premiums covered by Employer ABC.

An employee shall not accrue vacation, sick leave, or holiday benefits during a Leave of Absence.

An employee on probation shall have the probationary period extended by the length of the Leave of Absence.  If the length of the leave does not affect the employee's performance evaluation, a department manager can choose not to extend the employee's probation.

A medical leave approval requires medical information indicating the nature of the illness or injury, the prognosis, and estimated date of return.  In addition, the Employer shall require, prior to the employee's return to work, written approval from his or her doctor to resume job duties.  Employees are required to sign a form authorizing release to the Employer of any and all medical information prior to granting a Medical Leave of Absence.


Requests for leaves of absence over 24 working hours in a week shall be made on the "Leave of Absence Request" form.

·         The immediate supervisor shall approve a Leave of Absence requested on a “Leave of Absence Request” form.

·         The employee shall contact Financial Services to make all necessary arrangements for insurance coverage.  This includes determining the appropriate insurance premiums, the method of payment, and date payment is due.  If payment is not received when due, the Employer shall discontinue all insurance coverage without further notice.

Leaves of Absence of 24 working hours or under in a pay period shall be requested on a “Supplementary Leave of Absence Request" form.

·         The Department manager may approve a Leave of Absence of 24 working hours or less.

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