UNITE HERE Local 274 LOA/Short-Term Hires Confirmation Form

UNITE HERE Local 274 LOA/Short-Term Hires Confirmation Form
Name of Person Filling Out this Jotform
What type of short-term hire is this?

New short-term hire / LOAExtension of current short-term hire / LOA
Name of Short-Term Hire*

First NameLast Name
Short-Term Hire's Intended Start Date on Payroll with L274*

MonthDayYear
Date
Short-Term Hire's Intended Last Day on Payroll with L274*

MonthDayYear
Date
Short-Term Hire's Personal Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Is the Short-Term Hire coming out on an LOA from a UNITE HERE Workplace?*

YesNo
Name of the Local 274 Workplace
Has the LOA been approved by the Employer for the dates above?

YesNo
It is the lead/director's responsibility to communicate with the Operations Director once the LOA has been approved, or if it has been denied or modified.
What contractual benefits will the employer continue to contribute to during the LOA, for which Local 274 will be invoiced?

Health and WelfarePensionLegal Services FundScholarship FundTraining FundHousing Fund
Does the short-term hire have to make a contribution toward their healthcare benefits?

YesNo
Have they been informed of their obligation to pay this portion while on leave?

YesNo
Should the Short-Term Hire be added to Local 274's UNITE HERE Health Plan (only answer "Yes" IF: 1) this has been approved by your director; 2) the short-term hire is *not* continuing their health care from their employer; and 3) the short-term hire has indicated to you that they want to be added to the health plan.

YesNo
Will the Short-Term hire be driving a car as part of their assignment?

YesNo
Will they be driving their own car, or a rental?

Own CarRental
Please make sure you have confirmed that the short-term hire must bring their valid license, registration, and proof of insurance on their first day of work.
Should be Empty:

UNITE HERE Local 274 LOA/Short-Term Hires Confirmation Form

It is the lead/director's responsibility to communicate with the Operations Director once the LOA has been approved, or if it has been denied or modified.

Please make sure you have confirmed that the short-term hire must bring their valid license, registration, and proof of insurance on their first day of work.