1009 A1 Sample Military Leave Approval Letter
Georgia Department of Human Services |
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Sample Military Leave Approval Letter |
[Insert Date]
Dear [Insert Employee Name]:
This acknowledges receipt of your military orders that indicate you have been called to active duty beginning _________________ and ending ___________. If subsequent military orders lessen or extend the period of active duty, you are to provide a copy of those orders to me as soon as possible.
You will be placed on military leave with pay beginning ________________ through ________________, and will be paid for eighteen (18) workdays (not to exceed 144 work hours). Effective ________________, you will be placed on military leave without pay for the remainder of your active duty.
While on military leave without pay, health insurance and flexible benefits may be continued by paying the monthly premiums. You may elect to discontinue health insurance coverage while you are on military leave without pay. If you elect to discontinue coverage, there will be no forms to complete. However, please be advised if you do discontinue coverage your dependents will not be covered. Upon your return to work, health insurance coverage will resume on the first of the month following the appropriate premium deduction.
If you decide to continue health insurance benefits while on military leave without pay you must complete the attached Request to Continue Health Benefits during Leave of Absence without Pay Form and attach a copy of the military orders. All premium payments (check or money order) should include your social security number and are to be made payable to the State Health Benefit Plan for $_________. This includes a $1.00 processing fee. Prepayment of the first premium is required and should be mailed on or about the first of ________ for ___________ coverage.
Please mail your first payment to _________________________ the DHS Benefits Coordinator in the Office of Human Resources. Subsequent monthly payments for health insurance premiums do not require submission of forms with the payment and should be sent no later than the 15th of the month directly to:
State Health Benefit Plan
P.O. Box 38342
Atlanta, Georgia 30334
You may elect to discontinue your flexible benefits. If you elect to discontinue coverage, there will be no forms to complete. Upon your return to work, flexible benefits coverage will resume on the first of the month following the appropriate premium deduction.
If you elect to continue your flexible benefits while on military leave without pay, all payments (checks or money orders) should include your social security number and are to be made payable to the Flexible Benefits Program in the amount of $_______________. Please mail this payment directly to:
Flexible Benefits Program
Suite 1016, West Tower
200 Piedmont Avenue
Atlanta, GA 30334-5600
The above payment should arrive no later than the 20th of each month beginning with the first payment in _____________ for ______________ coverage.
You may elect to continue Group Term Life Insurance through the Employees' Retirement System (ERS) while on military leave without pay. You must provide ERS with a written notice to extend the coverage of group life insurance prior to your leave without pay. A copy of the form is attached for your use. The request will not be valid until received in the ERS office. Premiums in the amount of 1% of the monthly salary prior to the leave accumulate each month while on leave without pay and are due at the time of refund or retirement.
Attached is a copy of DHS Human Resources Policy #1009 - Military Leave your information. This policy provides the time frames for returning to work with the Department of Human Services following completion of your military leave as well as other information.
If you return to work following military leave you may pay contributions to the Employees' Retirement System and Deferred Compensation Program for the time period that the contributions were not paid during the military leave. You should contact the Employees' Retirement System and Deferred Compensation Program regarding applicable time frames.
Should you have any questions on the above, please contact _____________ at _________ (phone number).
Sincerely,
[Employee’s Supervisor Signature]
[Insert Employee’s Supervisor Name]