Excellacare Employee Time Off Request Form

This form is for Excellacare employees to request day(s) off that are fewer than 7 consecutive days. This form MUST be submitted at least 14 days (2 weeks) ahead of the day requested off. Please allow 5 business days for approval.

If you are requesting more than 7 consecutive days off, please call Excellacare at (248) 476-9091 for an Employee Leave of Absence form.

Name

First Name

Last Name

Phone

(###)

###

####

Email

Reason You Are Requesting Off

Last Day You Will Be Working

Please enter in MM/DD/YY format.

Day(s) You Are Requesting Off

Please enter in MM/DD/YY format.

Day You Will Be Returning to Work

Please enter in MM/DD/YY format.

Client Schedule(s) You Will Be Absent For

By checking here, you understand that by completing this form, your request is PENDING. Your request will be reviewed and you will be contacted via email or text letting you know if the time has been approved or rejected.

I understand my request above is pending approval, and I will be contacted via email or text by Excellacare once my request has been approved or rejected.