Benefit Forms

Dependent Verification Requirements

Domestic Partnership Affidavit

Certification of Healthcare Provider Form (LOA-Related Form)

You and your doctor (or your family member’s doctor if taking a care of a family member leave) must complete this form if you are taking a medical leave for yourself, pregnancy/childbirth leave or care of a family member leave.

Healthcare Provider Status Form (LOA-Related Form)

You and your doctor must complete this form if you are taking a medical leave for yourself in order for your doctor to indicate you are released to return to work at the end of your leave of absence.