ICS
ICS

Forms

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The forms listed below may be used as substitutes for employer-specific forms provided in your initial leave packet. For further information or if you have any questions, please contact ICS at benefits@innovativecaresystems.com or
1-800-965-1444.

Form Number Description Completed by Purpose
Disability Forms
ICS-DIS01ICS Attending Physician Statement Employee’s physician Certify period of disability
ICS-DIS02ICS Employee Statement Employee Request time off for a disability
ICS-DIS04ICS Authorization to Release Information Employee Authorize ICS to communicate
ICS-DIS05ICS Elective Deduction Form Employee Notify ICS of elective deductions
       
Paid Family Leave Forms
ICS-PFL02ICS Application for PFL Benefits              Employee Request paid family leave benefits
ICS-PFL03ICS Bonding Certification Employee Certify child related to bonding request
ICS-PFL04ICS Physician Certification Family member’s physician     Certify family member's serious health condition
ICS-PFL05ICS Statement of Care Recipient Person you intend to care for Certify employee as caregiver
       
Leave of Absence
ICS-LOA01ICS Certification of Healthcare Provider Employee's physician Certify serious health condition related to your request for family medical leave (FMLA)
       

 

ICS