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Insurance Coverage Continuation Form(during Family and Medical Leave)Name: S.S.# Emil. ID: Date of Leave: Continue? YES / Current Coverage:Option or TypePremium Employer Employee×Health Dental Life
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Who needs during family and medical?

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Employees who have a qualifying family or medical situation and need time off or require certain benefits may need to fill out family and medical documentation.
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Individuals seeking leave for the birth or adoption of a child, to care for a family member with a serious health condition, or to attend to their own medical needs may be required to complete family and medical forms.
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Employers may also require employees to fill out such forms to document their eligibility for family and medical leave or benefits.
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During family and medical leave, employees can take time off work to care for a family member or for their own medical needs.
Employees who are eligible for family and medical leave under the law are required to file for it.
Employees can fill out the necessary paperwork provided by their employer or the relevant government agency.
The purpose of family and medical leave is to allow employees to take time off work for family and medical reasons without risking their job security.
Employees must report details about the family member they are caring for or their own medical condition, as well as the duration of leave needed.
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