Employee Information
Please enter your name.
Please select your approver.
Time Off Details
Start date is required.
End date is required.
Please select at least one type.
Please select Yes if either applies:
• You are taking 10 or more workdays off
• You are taking 3 or more days for a medical procedure (for yourself or a family member in your care)
• You are taking 10 or more workdays off
• You are taking 3 or more days for a medical procedure (for yourself or a family member in your care)
Please select Yes or No.
Member Coverage Plan
Confirm your coverage arrangements before submitting. Your approver will receive this information with your request.
Please describe your coverage plan.