Employee Application for Intermittent Bonding Leave

Claim Number: ________________________

Employees Name:

Employees ID No.:

Address

Home Telephone No.:

City, St. Zip

Managers Name:

Employees Current Work Schedule

Employees Current Work Status

i.e. M-F 8 hours per day

Managers Contact Tel No.:

Full - Time

Part - Time

Employees Reason for Leave:

To Care for a newborn within 12
Months of the date of birth

An employee requesting intermittent leave to care for a newborn within 12 months of the date of birth
must submit a complete application for intermittent bonding leave to MetLife Disability within 15
calendar days of notifying MetLife of your need for an intermittent leave.

To care for an adopted or foster child within 12 months of the date of placement

An employee requesting intermittent leave to care for a newly placed adopted child within 12 months
of the date of placement must submit a complete application for intermittent bonding leave to MetLife
Disability within 15 calendar days of notifying MetLife of your need for an intermittent leave.

Requested Intermittent Leave Start Date:

Requested Intermittent Leave End Date:

Requested Intermittent Frequency:

Requested Intermittent Frequency Episodic Duration:

i.e. 2 days a week

(i.e. up to 4 hours a day)

Specify Day (s):

Th

Fri

Fax To Met Life At: (800) 230-9531

Remember to submit tracking sheets weekly whether time is taken or not

Please read each of the following:

I have informed MetLife of my need for intermittent bonding leave.

I understand that Verizon Wireless is not required by law to grant this leave but allows employees, at the discretion of its management and/or Human Resources and subject to its business needs, to
take up to 12 weeks of unpaid FML over a rolling 12 month period on an intermittent basis, to care for a newborn within 12 months of the date of birth,
to care for an adopted or foster child within 12 months of the date of placement

I understand that under the Family and Medical Leave Act of 1993, need for leave to care for a newborn within 12 months of the date of birth, to care for an adopted or foster child within the first
12 months of the date of placement requires that this leave be taken on a continuous basis, unless otherwise authorized by Verizon Wireless.

I understand that proof of birth of a newborn child or proof of placement of an adopted/ foster child is due within 15 days from the date I filed this claim.

I understand that a husband and wife eligible for Family and Medical Leave, who are employed by the same employer, are limited to a combined total of 12 weeks of leave during any 12 month
period if the leave is for the care of a newborn within 12 months of the date of birth, to care for an adopted or foster child within the first 12 months of the date of placement. You may obtain
additional information regarding leave entitlements for a husband and wife employed by the same company at http://aboutyou.verizonwireless.com.

I understand that if my need for leave is certified by MetLife in error and I do not have FML time available, do not comply with the certification requirements or eligibility requirements (worked
1250 hours in the past 12 months), my absences may be denied. If denied, my absences will count toward my attendance and may be subject to applicable disciplinary action.

I understand that I must submit my application for intermittent bonding leave or an extension of my leave to MetLife within 15 calendar days of notifying MetLife of the need for leave. If my
absences associated with this leave request exceed the frequency and duration requested on this form, I will be required to submit a new form within 15 calendar days of notifying MetLife of the
time taken in excess. If I do not submit a new form to MetLife within 15 calendar days, I understand that the time taken in excess of the frequency and duration requested on this form will be
denied.

I understand that approval for STD, LTD and /or Workers Compensation benefits do not provide job protection and job reinstatement following a leave of absence under FMLA. Job protection
and job reinstatement following a leave of absences will only be granted if I am approved for FML.

I understand that if I do not submit my application for intermittent bonding leave or an extension of my leave to MetLife within 15 calendar days of notifying MetLife for the need for leave my
claim will be closed. If my claim is closed, I will be required to file a new claim. If I file a new claim, any absences related to my need for bonding leave will be evaluated from the date I file a new
claim. Absences related to my leave prior to the date I file a new claim may not be considered under FMLA.

I have read and understand all of the above information and certify it to be true and accurate. I understand that if I fail to submit a complete application or if
my application is denied, if absent, I may not have job protection for intermittent bonding leave and may be terminated under Verizon Wireless attendance
policies.

Signature: _________________________________________
Revised: 09/14/2007

Date: _______________________________

Intermittent Bonding Leave Certification Form

Claim Number: _____________________________
Name of Employee: __________________________________

Employee ID No.:__________________________

To Be Completed by Manager

1. Employee Reason for Leave

The above named employee has requested an intermittent leave of absence under the Family and Medical Leave Act of 1993 (FMLA). Verizon Wireless allows an employee, at the discretion of
their manager and subject to its business needs, to take an intermittent leave of absence for one of the following reasons:
To Care for a newborn within 12
Months of the date of birth

An employee requesting intermittent leave to care for a newborn within 12 months of the date of birth
must submit a complete application for intermittent bonding leave to MetLife Disability within 15
calendar days of notifying MetLife of your need for an intermittent leave.

To care for an adopted or foster child within 12 months of the date of placement

An employee requesting intermittent leave to care for a newly placed adopted child within 12 months
of the date of placement must submit a complete application for intermittent bonding leave to MetLife
Disability within 15 calendar days of notifying MetLife of your need for an intermittent leave.

2. Managers Approval
Do you as the Manager approve the above named employees intermittent leave of absence?

Yes

No

Frequency and Duration (I.e. One day per week for the next four weeks on Wednesdays):
_____ Day(s) Per __________For The Next ____________________

On

Th. Fri.

(Specify Days (s)

Approving Managers Name:

Approving Managers Tel. No.:

Approving Managers Signature:

Date:

Fax To Met Life At: (800) 230-9531

Remember to submit tracking sheets weekly whether time is taken or not

Please Note: If the manager does not approve the employees leave, please forward this entire form to the attention of Human Resources

3. Manager Denials (If Applicable)

Only complete this section if no, in section 2
Briefly describe the reason manager has denied the employees request:

4. Final Review - HR Use Only:

Does HR Rep. Agree with the managers decision to deny the employees request?

Yes

HR Rep Printed Name:

HR Rep Tel. No.:

HR Reps Signature:

Date:

If HR has additional questions, please contact Employee Relations

Revised: 09/14/2007

No