DNR SOP –HR604 Attachment #1

Military Activation Form

Employee Information:
Name: / Employee ID:
Work Location: / Division:
Home Phone #: / Mobile Phone #:
Personal Email Address:
Military Orders:
Yes No / I have been ordered to military duty and am aware that I am eligible to be paid for up to 144 hours
while engaged in performing military duty. I have included a copy of my military orders.
Yes No / I have been ordered to military duty by emergency declaration of the Governor. I understand that Iam eligible to be paid for up to 96 additional hours while engaged in performing military duty. I haveincluded a copy of my military orders.
Leave Request:
Yes No / I wish to useONLYMilitary Leave. Upon exhausting my Military Leave, I acknowledge I will be placed on Military Leave without Pay (LWOP).(See attached leave request.)
Yes No / I wish to use Holiday Deferral, FLSA Comp time, Annual Leave,Personal Leave and/orGa. Comp time when my Military Leave is exhausted. Upon exhausting my designated amount of leave usage, I acknowledge I will be placed on Military Leave without Pay. (See attached leave request.)
Yes No / If still activated October 1st, whenanadditional 144 hours of military leave is allotted, I elect to be placed back in pay status for the designated period of time. Upon exhausting my Military Leave, I acknowledge I will be placed back on Military Leave without Pay. (See attached leave request.)
Health Insurance Coverage:
I am aware that to continue my Health Insurance Coverage while on Leave without Pay, I must make payments to DNR. Upon receipt of this form in the DNR Office of Human Resources, I will be contacted regarding these payments.
Flexible Benefits:
I am aware that once my record in TeamWorks reflects Leave without Pay,a system generated notice will be sent to me, from GaBreeze, describing what actions I must take regarding flexible benefits coverage. It is my responsibility to take action as necessary to continue my flexible benefits.
Group Term life Insurance:
I am aware that to continue my Group Term Life Insurance coverage through the Employees’Retirement System while I am on Leave without Pay, I must complete a Group Term Life Insurance Continuation While on LWOP form and submit it to the Employees’Retirement System.(The DNR Benefits Coordinator will send this form to me upon receipt of this request. It is located at
Return from Activation:
Upon my return from Activation, I understand:
  • My Health Insurance Coverage (if applicable) will be reinstated when I return to employment after military service.
  • My Flexible Benefits Coverage(if applicable) will be reinstated when I return to employment after military service.
NOTE:Employees who are on Military Leave during the Open Enrollment Period will have 31 days from the date they return to active status to make changes to their Health Insurance coverage and 30 days from the date they return to active status to make changes to their Flexible Benefits coverage.
  • Employees returning from a Military Leave without Pay have up to 5 years to buy their creditable service time from the Employees’ Retirement Systemfor the period of Military Leave without Pay to apply towards retirement.

Employee’s Signature: / Date:
For DNR HR Office Use Only:
Contacted Employee / Date: / Initials:
Sent Insurance Coverage Letter / Date: / Initials:
Sent GTLI Form / Date: / Initials:

Retain permanently in the official personnel file.

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