Temporary Paid Leave Application

Qualifying Reasons for Leave:

Under the FFCRA, an employee qualifies for paid sick time if the employee is unable to work (or unable to telework) due to a need for leave because the employee:

1. is subject to a Federal, State, or local quarantine or isolation order related to COVID-19;
2. has been advised by a health care provider to self-quarantine related to COVID-19;
3. is experiencing COVID-19 symptoms and is seeking a medical diagnosis;
4. is caring for an individual subject to an order described in (1) or self-quarantine as described in (2);
5. is caring for a child whose school or place of care is closed (or child care provider is unavailable) for reasons related to COVID-19; or
6. is experiencing any other substantially-similar condition specified by the Secretary of Health and Human Services, in consultation with the Secretaries of Labor and Treasury.

Under the FFCRA, an employee qualifies for expanded family leave if the employee is caring for a child whose school or place of care is closed (or child care provider is unavailable) for reasons related to COVID-19.

I am applying for the benefit because I meet the qualifying reason # (please refer to list above and make your selection below).

Your Application is Subject to Approval

Your application for Temporary Paid Leave Benefit will be reviewed and  additional information will be requested to document your reason.  You will be contacted shortly to complete your documentation.  You will receive your benefit when it is approved.

ID Proof and e-Signature Permission

By the use of my name, employee #, and store where I am employed, I agree is proof of my identity.  By entering my name initials and clicking on the "Submit" button below, I am agreeing that to be an electronic signature and confirmation of my intent to apply for these benefits.