Request for Lunch Break Waiver

Request for Lunch Break Waiver

Bluegrass Care Navigators | Everent Health | Hosparus Health
Employee Name*

First NameLast Name
Manager's Email Address*
example@everenthealth.org
Under Kentucky law, the Company must provide an employee an unpaid lunch or meal period no sooner than three (3) hours after her or his work shift commences and no more than five (5) hours after the work shift commences. Upon mutual agreement between the Company and employee, the required lunch break may be waived. KRS 337.355.

The Company recognizes that there are occasions when it may not be advantageous or convenient to take an unpaid lunch break, and if requested, the Company will provide the mutual agreement and consent to waive the required unpaid lunch break.

I, First Name Last Name , understand that the Company is required to provide a lunch break and am requesting to waive my unpaid lunch break. Upon mutual agreement, and by signing this form, I am waiving my right to an unpaid lunch break. I understand that at any time I may choose to revoke the waiver of my lunch break and will inform my supervisor of this decision.
Employee Signature*

Clear
Date

MonthDayYear
Date
HR Approving Signature

Melissa Merrifield
Date

MonthDayYear
Date
Should be Empty: