Leave of Absence without Pay
To be completed by Benefits Administrator
GENERAL INFORMATION
Participant Name:
Social Security #: - -
Leave of Absence Start Date:  
Leave of Absence Return Date:  
Institution/Campus:
Comments:
 
BENEFITS ADMINISTRATOR INFORMATION
Administrator Name:
Email:
Please make sure the above email address is correct. A confirmation notice and additional instructions will be emailed to this address.
Telephone: ( ) -