Type of Claim :
FMLA for Self
Intake Form :
#5357806
ALAQUINEZ
First Name :
MARCOS
Nickname :
Date of Birth :
01/04/2001
Middle Init. :
Gender :
Male
PERSONAL INFORMATION
Last Name :
Email Address :
marcosmccu0104@gmail.com
HOME ADDRESS
Street Address (Home) :
3527 BOTTOMLESS LAKE
Line 2 (optional) :
City :
SAN ANTONIO
State / Province :
TX
Zip Code :
78222
Home Phone Number :
(210) 531-6022
Which address would you like us to mail communications to
you? :
My eServices Account
REASON FOR LEAVE
Reason For Leave :
Positive covid test
RETURN TO WORK INFORMATION
What was or will be your last
day of Work :
04/19/2022
First Leave Date :
Have you returned to Work? :
No
What is your estimated return to work
date :
04/25/2022
04/20/2022
INTERMITTENT OR CONTINUOUS
Are you requesting Leave on an intermittent / part-time
basis? :
No
ADDITIONAL INFORMATION
Date of Hire :
04/09/2021
Original Date of Hire :
The person completing the
form is the person
requesting the leave of
absence? :
No
Temporary Contact
Address1 :
Temporary Contact
Address2 :
Temporary Contact City :
Temporary Contact State :
Temporary Contact Zip :
Temporary Contact Address
Date :
Temporary Contact Home
Phone :
04/09/2021
Temporary Contact Cell
Phone :
What are the dates you can reach at the address?
Temporary Contact Start
Date :
Temporary Contact End
Date :
WORK INFORMATION
Location :
96120 SAN ANTONIO TX DC
Job Title :
GENERAL WAREHOUSE
Employee ID :
002768744
Are you a full time
employee :
Yes
Are you Salaried? :
No
State :
TX
Work Phone Number
(including area code) :
Do you work Monday through Friday 8 hours per day? :
Yes
SUPERVISOR AND HR INFORMATION
Supervisor/Manager's Name :
BRANDON-RAYMOND FLORES
Retail Supervisor Name :
Supervisor/Manager's Email
Address :
bflores@dollargeneral.com
HR Rep Email :
Supervisor/Manager's
Phone :
Retail Supervisor Phone :
MISC. INFORMATION
Additional Comments :
if you can contact me asap on how i can upload my covid test results pls and thank you
FMLA SELF QUESTIONS
Was the disability caused by work :
No
Have you ever had a previous disability with this company? :
Have you been out of work on a leave of absence for this
same medical condition in the past 12 months? :
Describe your level of physical activity at work :
PHYSICIAN INFORMATION
When was your last
scheduled office visit :
When is your next scheduled
office visit :
Is Injury Caused by
Someone? :
Injury Details :
Health Insurance Provider :
Return with Restriction Flag :
Other
Health Insurance ID Number :
Receive Any Other Income :
Source of Other Income :
Restriction Description :
INCOME INFORMATION
Have you ever worked for DOLLAR GENERAL as a temp employee? :
No
CUSTOM QUESTIONS
If you are filing this claim for someone else, what is your name?
n/a
What is your relationship to the person you are filing for? If self, leave blank.
n/a
What is the best phone number to reach the person who filed the claim?
21053160222
Are you on leave due to restrictions that Dollar General is unable to accommodate? If yes, please be sure to fax your
restriction note to 877 788 9736.
n.a
Dollar General offers free assistance through an Employee Assistance Program that provides confidential consulting for
family and health related issues along with legal and financial help. This program has assistance for recovery problems,
resources for seniors and childcare, and any stress-related issues you may need some help with. We are happy to connect
you now, or you may also contact this provider at 1-866-234-3239 at a later time. Would you like us to transfer you at the
end of this call?
n/a
Is this a work related injury? If yes, All Dollar General employee injuries should be reported to the store manager or
manager on duty and reported via the 24-Hour Employee Incident Reporting Hotline @ 1-800-456-9446 within 24 hours and
prior to seeking non-emergency medical treatment.
n/a
REMINDERS
It is your responsibility to ensure your contact information is accurate at all times, including but
limited
to
your
address
and
telephone
number.
Please
log
onto
DGme
www.DollarGeneral.com/DGme to confirm and verify your contact information matches
information on this form. If any information on this form is not correct log onto DGme to make
necessary changes. Also contact your Matrix Integrated Claims Examiner at 888-644-3550 with
updated information.
not
at:
the
the
the
Yes
If you have questions regarding benefit continuation during your leave, please contact Dollar
General's Benefits Service Center at: 1-855-ASK-DGHR and select option 2 then option 9 for more
information.
Yes
If you are taking a leave for your own health condition, you must provide a completed Return to
Work/Fitness for Duty Certification to Matrix at least two days prior to your return to work release
date. You will not be permitted to return to work until your Fitness for Duty form has been received.
Yes
Please be aware that you may receive automated phone messages from Matrix Absence Management.
These automated messages are intended to provide you with important information and updates
regarding your claim. If you receive one of these automated messages, there is no need to call us
back unless you have questions regarding your claim or the process.
Yes
Matrix Absence Management, Inc.
2421 W. Peoria Avenue, Suite 200, Phoenix, AZ 85029-4940