FMLA Event Notification

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FMLA Event Notification

[/vc_column_text][vc_column_text]Please complete the information below. If you have any questions regarding this form please call BASIC FMLA Service Representative at 800-444-1922 ext. 4.

Company Name *

Employee Name *

Employee ID# or last 4 digits of SS# *

Address *

Address 2

City *

State / Providence / Region *

Country

Email of person submitting form *

Gender *

Male

Female

Hire Date *

Work Status *

Date Event Begins *

Date Company Notified *

Date Event Ends

Relationship to Employee *

Job Title *

Regular Work Schedule *

Employee's Essential Job Functions

1st Dr's visit (within 7 days of first day of incapacity)

2nd Dr's visit (within 30 days of 1st day of incapacity)

Type of Leave *

Continuous

Intermittent

Hours worked previous 52 weeks *

Additional Comments

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Contact Us

BASIC Flex
P 800-372-3539
F 269-327-0716

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