Change of Status Form

CHANGE OF STATUS REQUEST

(Leaves of Absences)
Name:*

First NameLast Name
Position*
Classification*
Email*
example@example.com
What is your Change of Status Request?*
Effective Date of Request:*

MonthDayYear
Date
Expected Date of Return: *

MonthDayYear
Date
According to Article 20.7 (Benefits While on Unpaid Leave of Absence) of the collective agreement, Arcus will continue to pay the Employer’s share of the applicable health and welfare benefits for twenty (20) work shifts in this calendar year.

For any leave of absence or accumulation of leaves of absence in excess of twenty (20) work shifts, benefit coverage may be continued by you, provided that you pay the monthly cost of the benefit premiums in advance to Arcus.
I have read and understand that after 20 unpaid work days, Arcus will no longer cover benefits. Benefits can be continued with a self-pay option.*
We will need 2 weeks notice prior to you returning back to your position.

Leaves will be approved by Melanie Shanley, Director of HR. Any questions regarding your leave, please contact Melanie at melanie@arcus.email
Should be Empty:

CHANGE OF STATUS REQUEST