Here are both an example of a broad “bereavement allowance” policy—which doesn’t specify that leave may only be taken for the death of an immediate family member—and a sample employee statement. These samples are provided courtesy of Diana Gregory, SPHR, of Administaff’s Walnut Creek office.
Our HR Management & Compliance Report: How To Comply with California and Federal Leave Laws, covers everything you need to know to stay in compliance with both state and federal law in one of the trickiest areas of compliance for even the most experienced HR professional. Learn the rules for pregnancy and parental leaves, medical exams and certifications, intermittent leaves, required notices, and more.
[Company] recognizes that tragic events occur in all of our lives, and that time off to deal with these situations may be needed. Therefore, we have a
bereavement allowance of up to ________ [suggested: up to five] paid days off per 12-month rolling period. In addition, an employee may request to use up to
two weeks of accrued paid time off and/or request up to ________ days of unpaid personal leave. Employees must complete a Bereavement Statement and submit it to the human resources department.
I, [insert employee name], hereby request a Bereavement Allowance Benefit of ________ days off, due to a death that causes me deep grief.
I understand that I am eligible for ________ days off with pay and that ________ days will be time off without pay. However, I can [must] use any accrued paid time off before taking unpaid time. I understand that the maximum time off for bereavement leave, both paid and/or unpaid, is ________ days per 12-month rolling period. If I need additional time off, I must apply for a personal leave of absence.
If this request is approved, I understand that I will have used ________ days of my maximum ________ days of paid bereavement leave for the 12-month period
(which begins on the date of my first bereavement day off in the last 12 months).
Signature: _______________________________________________________________
Date: ___________________________________________________________________
Approved: __________________________ Not Approved: __________________________
Date: ___________________________________________________________________
By: _____________________________________________________________________
Title: ____________________________________________________________________