Name:	Employment Date:	Phone#: ( ) -

GENERAL INFORMATION

IMA will consider requests for unpaid personal leaves of absence for leaves not related to your own medical
condition. Approval or denial of such requests will be entirely at the Company’s discretion. In determining the feasibility of granting such requests, factors such as the purpose of requested leave, availability of coverage for job responsibility during the requested leave, previous absences, length of employment, prior work records and performance and similar considerations, will be considered. However, if the request for a personal leave of absence is covered by a different Company policy or applicable law, the Company will apply its policy and will comply any applicable laws. Use of IMA’s LifeBalance PTO Policy is not permitted while taking an Unpaid Personal Leave of Absence.

DURATION OF LEAVE

A leave of absence should not exceed twelve weeks. A personal leave of absence for a longer period of time will be
considered on a case-by-case basis, but in all cases, if an employee is eligible for leave beyond that provided under this policy, the Company will comply with such requirements.

Associates on leave are asked to confirm their return date at least two weeks before they return to work. Any requests for additional leave must be made as soon as possible. Associates on leave who do not return as scheduled and fail to request or cannot show good reason why an extension should be granted, will be considered to have been voluntarily terminated from their employment as of the day the original leave expired.

I am applying for an unpaid Personal Leave of Absence, as follows:

Proposed Commencement Date of Unpaid Personal Leave of Absence:

Proposed Return Date of Personal Leave of Absence:

BENEFITS COVERAGE DURING LEAVE

During a qualifying personal leave of absence, and depending on your current health plan, you may be able to continue coverage under IMA’s health plans subject to and in accordance with the applicable terms and conditions of IMA’s then existing health plans. If you are not eligible to continue coverage on a health plan, you will receive notice from IMA pursuant to the Consolidated Omnibus Budget Reconciliation Act (COBRA) with information regarding options for continuation of health coverage. If you are eligible to continue coverage, you must continue to make the same contributions that you would have made for group insurance had you not taken the personal leave. Failure to pay your share of the health insurance premium may result in loss of coverage. If you fail to return to work after the expiration of the personal leave, you will be required to reimburse IMA for its share of the insurance premiums paid during the personal leave, unless contrary to applicable law.

If my leave is approved and I am currently enrolled in benefits (Check the box):

I wish to pay all of my employee benefit premiums in advance of my approved leave through payroll deduction.

I wish to be invoiced for my employee benefit premiums.

Please explain in detail the reason for your time off request:

PERSONAL LEAVE APPROVAL

Please confirm approval of the requested personal leave by signing below.

Approved requests must be sent to Human Resources at HRBenefits@imacorp.com for final approval, to facilitate the leave. If you have any questions regarding your leave request, please contact your HR Business Partner.

ASSOCIATE ACKNOWLEDGEMENT

Associate acknowledges the following:

If a personal leave of absence is granted, IMA cannot guarantee reinstatement or, should you return to work, cannot guarantee the same job or salary you held at the time of leave. Personal Leaves of Absence are granted for those rare and unique circumstances where no other leave provisions apply in an effort to support our associates.

Personal Leave is unpaid unless you are otherwise entitled to paid time off.

All time off must be requested at least 30 days in advance, or if unforeseeable, immediately upon knowledge of the need for time off.

If the approved dates for leave change you must update your manager and leave manager as soon as possible. When you are ready to return to work, you must update and coordinate your return from leave at least three business days in advance with your manager and the HR leave manager.

Failure to return from an approved Personal Leave may be considered job abandonment and the attendance policy will apply.

Associate further acknowledges that IMA Financial Group, Inc. may alter, amend, or terminate this program from time to time.

Associate Signature	Date

Manager or Supervisor’s Signature	Date

HUMAN RESOURCES USE ONLY: Application Received On: The leave of absence is approved and has been recorded in the HR system Payroll has been notified Date: _______________ Human Resources Contact: ____________________