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	<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
	<html>
	<head>
	<title>UCLA Health System - Human Resources: Benefits Forms</title>
	<meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
	<meta name="description" content="">
	<meta name="keywords" content="benefits, ucla health system benefits, human resources benefits, human resources, forms">
	<style type="text/css">
		
		@import url(default.css);
		@import url("healthsystem.css");
	</style>
<script language="javascript" src="scripts/weather.js" type="text/javascript"></script>
	<script src="scripts/AC_ActiveX.js" type="text/javascript"></script> 
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var iLimit = 25;
var itmp = 0;

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var nbTimes = 2;
var nbThisLoc = 325;
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function nbImagePreload(img_name, mo_img_src, rollover_key_img_name) {
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}

function BillzMouseover() {
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}

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function NavBarSwapRollover(swapimage,defaultimage,imageID) {
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}
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function BillzNavBarMM_showHideLayers() {
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	var p = null;
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			if (obj.style) obj.style.visibility = (v == 'show') ? 'visible' : ((v == 'hide') ? 'hidden' : v);
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function NavBarLayer() {
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	this.MOutLayer = arg[2];
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}

function BillzNavMove() {
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}

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}

window.onload = FullyLoaded;
//-->
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//<!--
function NavBar_setCookie(cookievalue,navVersion,linkID) 
{	
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	var cookieClear = "SLIDINGTBL_NAVBAR_CLEARCOOKIES";	
	document.cookie = cookieClear.toUpperCase() + "=false";
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		document.cookie = cookiename.toUpperCase() + "=" + escape(cookievalue);
	if(navVersion.length > 0)	
		document.cookie = cookieVersionname.toUpperCase() + "=" + navVersion;	
	if(linkID.length > 0)
		NavBar_setPLinkIDCookie(linkID,navVersion);		
}
function NavBar_setoLevelIDCookie(cookievalue,linkID,navVersion) 
{
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}
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{	
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	if(navVersion.length > 0)	
		document.cookie = "SLIDINGTBL_NAVBAR_VERSION=" + navVersion;
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function NavBar_deleteCookie() 
{
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														<h1 class="pagetitle" id="pagetitle"><strong>Benefits</strong> / Forms</h1>
													
												
											
										
										
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	<ul>
<li><a href="documents/StatementOfHealth-LibertyMutual.pdf">Statement of Health Form (Liberty Mutual)</a> </li>
<li><a href="documents/University%20of%20CA%20LF%2097000.pdf">Statement of Health Form (Prudential)</a> </li>
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<h2>Leave of Absence Program</h2>
<h3><span style="text-decoration: underline;"><br /><a name="FMLA"></a>FMLA Packets</span></h3>
<ul>
<li><a href="workfiles/Benefits/FMLA_Packet-EmpSHC.pdf">FMLA Packet for Employee Serious Health Condition</a> </li>
<li><a href="workfiles/Benefits/FMLA_Packet-FamSHC.pdf">FMLA Packet for Family Member Serious Health Condition</a> </li>
<li><a href="workfiles/Benefits/FMLA_Packet-PregDis.pdf">FMLA Packet for Pregnancy Disability</a> </li>
<li><a href="workfiles/Benefits/FMLA_Packet-MilCareLeave.pdf" target="_blank">FMLA Packet for Military Leave Entitlement - Military Caregiver</a> </li>
<li><a href="workfiles/Benefits/FMLA_Packet-ExiLeave.pdf" target="_blank">FMLA Packet for Military Leave Entitlement - Qualifying Exigency</a> </li>
<li><a href="workfiles/Benefits/LeaveOfAbsenceRequest.pdf" target="_blank">Leave of Absence Request&nbsp;Form</a> (for all other leaves such as Personal Leave, Military Leave, Union Business, Professional Development, Administrative Leaves, etc.)&nbsp; </li>
<li>
<h3><a href="http://hr.healthcare.ucla.edu/Download/LOAGUIDE2.doc">FMLA User Guide - Employee &amp; Employer Rights and Obligations</a></h3>
</li>
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<h3><span style="text-decoration: underline;">Department Forms</span></h3>
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<li><a href="workfiles/Benefits/LeaveOfAbsenceChecklist.pdf" target="_blank">Leave of Absence Checklist</a></li>
<li><a href="workfiles/Benefits/LEAVE_OF_ABSENCE_REQUEST_NOTIFICATION.doc">Leave of Absence Request Notification (for MC Westwood Only)</a></li>
<li><a href="workfiles/Benefits/LEAVE%20OF%20ABSENCE%20NOTIFICATION.doc">Leave of Absence Notification</a> </li>
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