FORM B - PERSONAL LEAVE OF ABSENCE ALL NON FMLA LEAVE Team Member Name: Team Member Number: Date of Hire: Department: Department Manager Contact Phone Number: E-mail Address: Current Home Address: Alternative Contact Person: First day of absence: Extensions: 1st: Expected Return Date 2nd: Actual Return: Provide a brief explanation of the reason for Personal Leave Request *** Do Not Leave Blank *** CERTIFICATION AND AUTHORIZATION I certify that all of the information I have provided on this form is true and complete and that I have been given a copy of the rights and responsibilities of this Personal LOA. I understand that failure to comply with the rights & responsibilities may result in termination. Team Member Signature: Date: APPROVAL Page | 1 Department Head Signature: Date: Department Head Printed Name: Date: Division Head Approval: Date: Human Resources Signature: Date: FORM B - PERSONAL LEAVE OF ABSENCE ALL NON FMLA LEAVE PERSONAL LEAVE OF ABSENCE - RIGHTS AND RESPONSIBILITES (TEAM MEMBER TO KEEP) Requested Begin Date:____________________ Expected Return Date:_____________________ Manager Name & Contact Number: _________________________________________________ HR Contact: Erica Franck 305-695-4845 Any request for a Personal Leave of Absence must be submitted in writing as soon as the need for leave is known to the Team Member. Your leave will be reviewed on an individual basis by your manager and the decision to approve or not approve is generally based on the following circumstances:     The length of time requested. The effect the absence will have on the work in the department. The business needs of the department throughout the duration of the time requested. The expectation is that you will return to work when your leave expires. If you are granted a Personal Leave of Absence by your Manager the following rights and responsibilities will apply:            Page | 2 Fontainebleau cannot guarantee that your job will remain available; however, whenever possible, Fontainebleau will attempt to reinstate you to your former position or to one with similar responsibilities. If the position or a similar position is not available, you will be considered to have voluntarily resigned your position. Available vacation hours must be exhausted prior to unpaid leave being granted. Unemployment insurance benefits cannot be collected while on personal leave. When you return to work following a Personal Leave of Absence it will be considered as having continuous service. If you do not return from the Personal Leave of Absence, the termination date will become the last day of the authorized leave period or the date you notify your manager that you are not returning, whichever is earlier. I agree to notify my manager at least 3 days prior to my expected return to work date of my intention to return and to confirm my schedule. If you engage in outside employment while on personal leave you will be terminated immediately. If I am unable to return to work on or before my expected return date, I must immediately apply to my department head for an extension. If the extension is not approved I will be expected to return on the original approved return to work date. My employment will terminate if I do not return to my job on or before my expected return date or I do not comply with all the requirements. You can choose to cancel or remain on the group insurances. Pre-payment is required, if payment is not received all benefits will be canceled. If benefits are cancelled either by choice or due to nonpayment you will not be eligible to re-enroll until the next open enrollment. COBRA coverage will be offered to you if your benefits are cancelled. COBRA requires that you pay the total monthly premium plus an administrative charge. Vacation time is not accrued during a personal leave of absence. If provisions are in conflict with the collective bargaining agreement; the applicable provisions of the CBA shall take precedence. FORM B - PERSONAL LEAVE OF ABSENCE ALL NON FMLA LEAVE EXTENSION REQUEST If you are unable to return to work by your originally scheduled date, you may request an extension to your personal leave of absence by completing this form. However final approval is at the discretion of by your Department Head and will based upon the business needs of the Department. 1. Complete and sign this form. 2. Give this form and any documentation to your manager one week before your previously scheduled return to work date. 3. You will be notified of approval or denial by your manager 4. If the extension is not approved you will be expected to return on the original approved return to work date I, (print your name) ______________________________________ request that my leave of absence be extended from (write original return to work date) ______________________ to (write the date you now expect to return to work) ____________________________. The reason for this request is (write reason): _______________________________________________ __________________________________________________________________________________ Team Member Signature: ____________________________ Date:_____________________  Approved  Denied By Manager: (print name)__________________________________ Manager Signature:______________________________ Date:________________________ HR Representative Signature: _______________________ Date: _______________________ Page | 3 FORM B - PERSONAL LEAVE OF ABSENCE ALL NON FMLA LEAVE BENEFITS PAYMENT INFORMATION For FMLA or WC Industrial Leave: You are responsible for the employee portion of your current benefit premium deductions. If your benefits are canceled (because you canceled them or because of missed payments), you will be eligible to have the benefits you previously participated in start again when you return to work. Contact Linda DeLeon at extension 4719 in the Fontainebleau Human Resources Dept. within 15 days of your return to re-enroll in benefits. For Personal or non-FMLA Medical Leave: You are responsible to pay 100% of the current benefit premium (both employee and employer portions.) If your benefits are canceled (because you canceled them or because of missed payments), you may NOT be eligible for these benefits when you return to work. You must wait until the next Open Enrollment to apply for benefits. Submitting Payments:       All payments are due by the 1st of the coverage month being covered. Payments not received within 30 days of the due date are subject to cancelation 15 days later. Make check or money order payable to: The Fontainebleau Florida Hotel, LLC Your Social Security number MUST be included on your check or money order. Include a copy of the worksheet with your check or money order. Mail to: The Fontainebleau Florida Hotel, LLC., 4441 Collins Ave., Miami Beach, FL 33140, ATTN: Linda DeLeon, HR Benefits Administrator. Payments cannot pay for benefits beyond your LOA End Date. If an extension is approved, you may be asked to pay an additional amount to cover your benefits. Page | 4 FORM B - PERSONAL LEAVE OF ABSENCE ALL NON FMLA LEAVE BENEFITS PAYMENT WORKSHEET INSURANCE PAYMENTS SUBMITTED WHILE ON LEAVE OF ABSENCE Team Member Name: LOA Dates: Biweekly Pre-payment Period Ending Dates Benefit Type Medical Dental Vision STD LTD Vol Life EE Vol Life SP Vol Life CH Vol ADD EE Vol ADD SP Vol ADD CH Vol ACCID Vol CRIT Vol HOSCF PARKING Payroll Deduction Code EMPLOYEE Biweekly Amount for all LOA's Team Member # LOA Type plus EMPLOYER Portion for Personal & non-FMLA Medical LOA's Number of pay periods Total cost each Benefit Partial Pmt Breakdown 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 VLIFE VLIFS VLIFC ADDEE ADDSP ADDCH ACCID CRIT HOSCF Total Amount Paid $0.00 0.00 I agree that $________ can be deducted from my paycheck as Pre Payment for my benefits while I am on LOA. Period Ending date of Pre-Pay deduction is _______________________. Team Member Signature: ___________________________________ Date: ____________________ Accounting Confirmation: Received by: _______________________________________ Page | 5 Date: _____________________