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Leave Election Form Templates

Injured employees use these forms to specify whether they want to use personal leave during the seven-day benefit waiting period.


Injured employees are not eligible for weekly workers’ compensation income benefits until their absence exceeds seven calendar days. These forms, available in English and Spanish, allow injured employees to indicate whether they want to use paid leave during the seven-day waiting period. Employers should check their leave policy to verify whether they have an offsetting policy.