ZIPING LIU'S FMLA FROM MARCH 30TH TO ONGOING - ZIPING LIU HAS NOT HAD ANY MEDICAL REST

April 14, 2022 Ziping Liu 109 Spanish Oak Circle Lake Jackson, TX 77566 USA Action Required: Your leave request – Ziping Liu, Case 04073256 Ziping Liu, We have received your Leave request. Below you will find required next steps, your leave overview, pay information, and more. Submit required documentation by May 4, 2022, to avoid denial of benefits and leave.

Required Next Steps 1. In order to qualify for pay during your leave, WA state requires you to apply for paid benefits through the state of WA at https://paidleave.wa.gov/apply-now/ or Phone: (833) 717-2273.

2. After applying with your state, you must submit your state benefit decision letter to Amazon within 5 days of receipt. Submit your decision letter by replying directly to this email, on the Resources page at atoz.amazon.work, or via the Disability and Leave Services (DLS) Portal at dls.idp.amazon.corp.com (on the Amazon network).

3. Return the attached Physician’s Statement form or medical documentation supporting your leave request by May 4, 2022 (unless previously provided). Submit documentation by replying directly to this email, on the Resources page at atoz.amazon.work, or via the DLS Portal at dls.idp.amazon.corp.com (on the Amazon network).

4. Contact us if any of the information you provided changes, such as your leave start or end dates.

Your Leave Overview 

You requested time off from March 30, 2022 to April 15, 2022 due to your personal health condition.

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You expect to return to work on April 16, 2022.

You are eligible for leave provided by the federal Family and Medical Leave Act (FMLA). If your leave is approved based on the paperwork you provide, it will be designated under FMLA. Your time off work will reduce your available leave balance under FMLA:

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Your requested leave will use an estimated 2 weeks 24 hours of FMLA which leaves a remaining balance of 9 weeks 16 hours. This is an estimate and is subject to change if your leave dates change.

Pay Available During Leave   

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As an employee working in WA, your benefits will be a combination of state benefits and Amazon’s disability pay.

Your pay will be determined by the documentation you provide to the state and to Amazon DLS. You may also be eligible for Amazon’s Short-Term Disability (STD) plan administered in accordance with the terms of the federal Employee Retirement Income Security Act (ERISA). This is called “disability payment.” If approved, Amazon may offset the state’s payment to ensure that you receive a minimum of 60% of your weekly base pay.

STD pay will only begin after 7 days. You can use available Sick, Personal, Floating Holiday and/or Vacation time to cover this 7 day unpaid period.

Important Information You Should Know 

We are reviewing the leave plans for which you are eligible. We will apply the best benefit for your leave and pay benefits. A DLS team member will review your case and get in touch with you via your preferred contact method.

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You can enter available Sick, Personal, Floating Holiday, and/or Vacation time off via your A to Z Employee Self Service (ESS) Portal via atoz.amazon.work or DLS Portal on the Amazon network ( https://dls.idp.amazon-corp.com.)

Review the FAQs for information about when your benefits will begin, end, and how a leave of absence impacts your health benefits, pay and stocks, if applicable.

You can review your leave information on Amazon A to Z. Log in via atoz.amazon.work or use the app (download for Android or iOS). Please note that it takes 24-48 hours for all systems to reflect your active status.

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Questions?

Contact us by phone at 1-888-892-7180 Option 1 Ext.5494 or email at amazondls@amazon.com.

Thank you, Amazon DLS

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Attn: Ziping Liu 109 Spanish Oak Circle Lake Jackson, TX 77566

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FMLA Rights & Responsibilities Notice In general, to be eligible for FMLA you must have worked for an employer for at least 12 months, meet the hours of service requirement (1,250 hours) in the 12 months preceding the leave, and work at a site with at least 50 employees within 75 miles. You must also have FMLA entitlement available in the applicable 12-month period.

If your leave qualifies and is certified as FMLA, your absences will be designated as FMLA leave and will count against your FMLA entitlement.

Your Rights Under the FMLA 

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You are entitled to 12 weeks of unpaid leave in the 12-month period (26 weeks to care for a covered servicemember with a serious health condition), measured backward from the date of any FMLA usage (“rolling backward” calculation method).

You are not required to use accrued paid time off during your unpaid FMLA leave. You may supplement your leave with paid time off, if applicable. Any applicable conditions related to the usage of paid time off, as set by Amazon, will apply. If paid time off is used, the absences will also be designated as FMLA and will count against your FMLA entitlement. If you do not meet the conditions or requirements for usage of paid time off, you remain entitled to unpaid FMLA leave.

Your health benefits must be maintained during your FMLA leave, as if you continued to work.

You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from FMLA-protected leave. (If your leave extends beyond the end of your FMLA entitlement, you do not have return rights under FMLA. Certain circumstances, such as a reduction in workforce or your position no longer exists, could also prevent your reinstatement.)

Your Responsibilities Under the FMLA 

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If required by Amazon, you must submit sufficient certification or documentation in a timely manner, or your leave may be delayed or denied. If your leave is delayed or denied, any absences may be subject to the attendance policy and could result in termination.

You must make your share of any premium payments to maintain your health benefits. You have a minimum 30day grace period in which to make premium payments. If payment is not made timely, your group health insurance may be cancelled, provided we notify you in writing at least 15 days before the date that your health coverage will lapse, or, at our option, we may pay your share of the premiums during FMLA leave, and recover these payments from you upon your return to work. If you do not return to work, you may be required to reimburse Amazon for our share of health insurance premiums paid on your behalf during your FMLA leave.

You may be required to provide Amazon with periodic reports of your status and intent to return to work.

Generally, these updates will be required every 30 days, depending on the circumstances of your leave.

After we have obtained sufficient information to make a determination, we will notify you within five business days whether your leave will be designated as FMLA and count against your FMLA entitlement. If you have any questions, please contact the Disability and Leave Services (DLS) team at 1-888-892-7180, option 1. Representatives are available between 5:00 a.m. and 5:00 p.m. PST, Monday through Friday.

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Revised December 2019

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Revised December 2019

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FMLA Frequently Asked Questions 1.

What is the Family and Medical Leave Act (FMLA)?

The Family and Medical Leave Act (FMLA) provides eligible employees up to 12 workweeks of unpaid leave a year for various family and medical reasons, and requires group health benefits to be maintained during the leave as if employees continued to work instead of taking leave. Employees are also entitled to return to their same or an equivalent job at the end of their FMLA leave.

The FMLA also provides certain military family leave entitlements. Eligible employees may take FMLA leave for specified reasons related to certain military deployments of their family members. Additionally, they may take up to 26 weeks of FMLA leave in a single 12-month period to care for a covered servicemember with a serious injury or illness.

2.

Who can take FMLA leave?

In order to be eligible to take leave under the FMLA, an employee must:  work for a covered employer;  have worked 1,250 hours during the 12 months prior to the start of leave;  work at a location where the employer has 50 or more employees within 75 miles; and  have worked for the employer for 12 months. The 12 months of employment are not required to be consecutive in order for the employee to qualify for FMLA leave. In general, only employment within seven years is counted unless the break in service is (1) due to an employee’s fulfillment of military obligations, or (2) governed by a collective bargaining agreement or other written (2) agreement.

3.

When can an eligible employee use FMLA leave?

A covered employer must grant an eligible employee up to a total of 12 workweeks of unpaid, job-protected leave in a 12 month period for one or more of the following reasons:  for the birth of a son or daughter, and to bond with the newborn child;  for the placement with the employee of a child for adoption or foster care, and to bond with that child;  to care for an immediate family member (spouse, child, or parent – but not a parent “in-law”) with a serious health condition;  to take medical leave when the employee is unable to work because of a serious health condition; or  for qualifying exigencies arising out of the fact that the employee’s spouse, son, daughter, or parent is on covered active duty or call to covered active duty status as a member of the National Guard, Reserves, or Regular Armed Forces. The FMLA also allows eligible employees to take up to 26 workweeks of unpaid, job-protected leave in a “single 12-month period” to care for a covered servicemember with a serious injury or illness.

4.

Does Amazon allow FMLA leaves for domestic partners?

Yes, Amazon allows FMLA leave to be used to care for a domestic partner in the same way leave can be used to care for a spouse.

5.

Does an employee have to take leave all at once under FMLA or can it be taken periodically or to reduce the employee’s schedule?

When it is medically necessary, employees may take FMLA leave intermittently – taking leave in separate blocks of time for a single qualifying reason, or on a reduced leave schedule – reducing the employee’s usual weekly or daily work schedule. When leave is needed for planned medical treatment, the employee must make a reasonable effort to schedule treatment so as not to unduly disrupt the employer’s operation.

Leave to care for or bond with a newborn child or for a newly placed adopted or foster child may not be taken intermittently, per Amazon’s policy (FMLA for bonding can be taken in two segments), unless otherwise allowed by state/local law, and must conclude within 12 months after the birth or placement.

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FMLA Frequently Asked Questions 6.

What is a serious health condition under FMLA? The most common serious health conditions that qualify for FMLA leave are:  conditions requiring an overnight stay in a hospital or other medical care facility;  conditions that incapacitate you or your family member (for example, unable to work or attend school) for more than three consecutive days and have ongoing medical treatment (either multiple appointments with a health care provider, or a single appointment and follow-up care such as prescription medication);  chronic conditions that cause occasional periods when you or your family member are incapacitated and require treatment by a health care provider atleast twice a year; and  pregnancy (including prenatal medical appointments, incapacity due to morning sickness, and medically required bed rest).

7.

What happens to my health benefits while I am out on FMLA leave?

A covered employer is required to maintain group health insurance coverage, including family coverage, for an employee on FMLA leave on the same terms as if the employee continued to work. Where appropriate, arrangements will need to be made for employees taking unpaid FMLA leave to pay their share of health insurance premiums.

An employer's obligation to maintain health benefits under FMLA stops if and when an employee informs the employer of an intent not to return to work at the end of the leave period, or if the employee fails to return to work when the FMLA leave entitlement is exhausted. The employer's obligation also stops if the employee's premium payment is more than 30 days late and the employer has given the employee written notice at least 15 days in advance advising that coverage will cease if payment is not received. In some circumstances, the employer may recover premiums it paid to maintain health insurance coverage for an employee who fails to return to work from FMLA leave.

8.

What is the process when I request an FMLA leave?

Amazon may require that the need for leave for a serious health condition of the employee or the employee’s immediate family member be supported by a certification issued by a health care provider. Amazon may also require that the need for leave to care for a covered servicemember with a serious injury or illness or military qualifying exigency be supported by appropriate certification. The form must be submitted to the Leave of Absence and Accommodations (LOAA) team by the due date listed in your FMLA materials. If the certification is incomplete or insufficient, you will be notified, in writing that includes what additional information is required, and you will be given additional time to cure the deficiency. If you provide authorization/release, the LOAA team will also make attempts to clarify the information with the healthcare provider.

After the LOAA team receives a completed certification, your leave will be approved or denied based on the information that was received. You will be notified of the decision. If your FMLA leave is denied, you may be eligible for other leave options, including state or local leave laws or Amazon LOA policies.

9.

How long does it take the LOAA team to process an FMLA request?

After the LOAA team has sufficient information to determine whether your leave is FMLA-qualifying (for example, after your certification is received), you will be notified whether the leave will be designated as FMLA leave within five business days, absent extenuating circumstances.

10. How does FMLA leave impact any disability claim that I might have?

FMLA runs concurrently with any short-term disability (STD) benefits for which you are approved. FMLA will run during the approved STD period, if applicable, until FMLA entitlement is exhausted. Your STD claim will remain open for as long as you meet the requirements of the STD policy.

11. What happens if my FMLA request is denied?

You will be notified, in writing, including the reason your leave was not approved. You may be eligible for other leave options, including leave under state or local leave laws or Amazon LOA policies generally.

12. What happens if I am not able to return to work at the end of my approved FMLA leave?

You should contact the LOAA team, by calling 1-888-892-7180, option 1. You may be eligible for other leave options, including state or local leave laws or Amazon LOA policies. You may also be entitled to an accommodation, including leave of absence as an accommodation, under the Americans with Disabilities Act (ADA) and/or other applicable laws.

While this document is intended to provide a summary of general information regarding FMLA leave, in the event of a conflict between this document and the governing documents for any such benefits or policy, the terms of such governing documents will control. Please note these FAQs pertain only to the FMLA. An employee may have greater leave rights under state and local law.

Please contact MyLeave at 888-892-7180, option 1, if you have any questions about leave under state or local law.

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Short-Term Disability Frequently Asked Questions 1. When am I eligible to file for short-term disability benefits?

Any employee who is classified as a regular employee, and assigned to work a minimum of 30 hours per week may be eligible for short-term disability (STD) benefits after the employee has completed one day of work and any other eligibility requirements as contained in the Summary Plan Document (SPD), which at all times governs. In addition, you must also meet the following requirements in order to be eligible to receive disability benefits (or as otherwise required under the SPD):  Unable to perform the material and substantial duties of your own job due to illness, injury, or pregnancy,  Receiving regular and appropriate care and treatment for the illness or injury that is intended to aid in recovery and return to work, and  Not be working at any job, in order to receive the full disability benefit. (You may later be eligible for a partial benefit if you initially qualify and are then employed in your own job or another job, earning between 20% and 80% of your Basic Weekly Earnings.)

2.

When are STD benefits paid?

Amazon Disability & Leave Services (DLS) (or Amazon’s Third Party Administrator (TPA)) must receive proof that you are disabled due to injury or illness as defined in the SPD. You must satisfy a seven-day elimination period, meaning that the disability payment will begin on the eighth consecutive calendar day of an approved disability. For claims related to pregnancy (pre-partum or post-partum disability), you must be disabled for seven calendar days, after which the benefit will be paid retroactively to the initial date of disability or the date of delivery, whichever is earlier.

3.

Can I use my paid time off during the elimination period for short-term disability?

You can use available accrued paid time off, such as vacation or personal time, to cover all or part of the elimination period, if applicable. If you do not have enough paid time off to cover the entire waiting period, the portion that is not covered will be unpaid.

4.

Can I initiate my STD claim early?

You may call in your claim 90 days in advance of the start date of your leave of absence. No claim decision can be made until your disability is certified by your healthcare provider. When your date of disability arrives, Disability & Leave Services (DLS) or Amazon’s TPA will contact your healthcare provider to obtain the necessary information or certification, and confirm your date of disability.

5.

What benefits are payable for an STD claim due to illness or injury?

In general, after you satisfy the seven-day waiting period, you will receive STD benefits equivalent to 60% of your Basic Weekly Earnings, up to a maximum of $2,300 per week, less other income benefits or earnings (e.g., workers’ compensation or state/local disability benefits). Benefits are payable for up to 25 weeks, as long as you meet all provisions of the STD policy.

6.

What benefits are available for pregnancy-related STD claims?

In general, you will receive STD benefits equivalent to 100% of your salary or wages during the pre-partum disability period (four weeks prior to your estimated delivery date) and post-partum disability period (10 weeks after your actual delivery date).

7.

What is the process when I file an STD claim?

DLS or Amazon’s TPA will review the claim for eligibility. STD eligibility is dependent on the requirements listed in the STD policy. After your eligibility is verified, DLS or the TPA will:  Contact your physician to verify your disability and obtain documentation to support your disability, if applicable, and  Make a claim decision and notify you whether your claim is approved or denied.

Note: you and your healthcare provider must provide sufficient information by the due date listed in your packet, or your claim may be delayed or denied. Please review the entire packet as soon as you receive it and ensure that all required documentation is submitted in a timely manner. Contact DLS if you have any questions.

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Short-Term Disability Frequently Asked Questions 8.

What happens to my STD claim if my physician will not speak to DLS? DLS or Amazon’s TPA will contact you if we are unable to reach your physician or obtain sufficient medical information. If you submit a signed Authorization Form, DLS will work with your physician to obtain the necessary information. You may also be asked to contact your physician and have the necessary documentation supplied for your claim.

9.

How long does DLS need to process an STD claim?

A decision on an STD claim can typically be made within five business days. However, the time to process your claim depends on timely responses from you and your physician so that DLS or Amazon’s TPA has the necessary information to approve or deny a claim.

10. After my claim is approved, when will I receive my STD pay?

After a claim has been approved, you will receive your paycheck on the next scheduled pay date or on the designated date set by Amazon.

11. How does FMLA leave impact any disability claim that I might have?

FMLA runs concurrently with any short-term disability (STD) benefits for which you are approved to the fullest extent allowed by applicable law. FMLA will run during the approved STD period, if applicable, until FMLA entitlement is exhausted. Your STD claim will remain open for as long as you meet the requirements of the STD policy.

12. What is my role in the STD claim process?

You can expedite the claim process by promptly completing and returning the required documentation, and ensuring your healthcare provider submits the medical certification. Please advise your healthcare provider that DLS will be contacting him or her to confirm your disability and to obtain medical documentation.

During your STD claim, you must keep DLS or Amazon’s TPA informed of your progress and treatments, as well as any potential return-to-work information. Please ask your healthcare provider to respond to us in a timely manner regarding your ongoing disability status.

13. What should I do when my health care provider releases me to return to work after short-term disability? Contact DLS or Amazon’s TPA when your healthcare provider releases you to return to work. You may be required to submit a fitness for duty form certifying that you are able to return to work. We will coordinate all return-to-work arrangements.

14. What happens if I can return to work after short-term disability, but I have restrictions?

Notify DLS or Amazon’s TPA immediately upon discovering you have, or will have, return-to-work restrictions. We will coordinate your return to work and work with you to determine if we can accommodate your restrictions. If you have been released to return to work on a part-time schedule, you may continue to receive partial disability benefits for the work time you miss until your claim reaches a maximum benefit period or until you return to work full duty.

15. What happens if my STD claim is denied?

You will be notified, in writing, including the reason your claim was not approved. You will also receive information about the appeal process.

16. What happens when I exhaust my STD benefits?

When your STD benefits exhaust, you may qualify for long-term disability (LTD) benefits. Approximately two-thirds of the way through your STD claim, DLS or Amazon’s TPA will contact you to gather information about your potential return to work or your need for continued leave. If you remain unable to work, DLS will provide you with information regarding the LTD claim process. If you are not eligible for LTD benefits, or do not have this benefit, please contact DLS or Amazon’s TPA to learn about other options.

While this document is intended to summarize accurately the benefits described above, in the event of a conflict between this document and the governing plan documents for any such benefits, the terms of such governing documents will control.

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U.S. Guide to Benefits and Compensation During Leave of Absence (LOA) Revised December 2021

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What’s Inside 1. Overview 2. Medical-Related Benefits General Information Changes to Benefits Related to Qualifying Events COBRA Coverage: Medical, Dental, and Vision Coverage Basic Life and Accidental Death and Dismemberment (AD&D) Insurance (company-paid) Supplemental Life Insurance or Supplemental AD&D Insurance 3. Bonuses, Stock & 401(k) Benefits, PTO, DSPP Sign-On Bonus PTO, Vacation, and Attendance Policies , Suspension of Vesting and Cancellation , 401(k) Account and 401(k) Loans, Direct Stock Purchase Plan (DSPP) 4. Return to Work Position Reinstatement Reasonable Accommodation 5. Important Provider/Contact Information

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Overview This guide will help you understand Amazon leave policies and how your leave may affect employment and benefits. This guide provides only a summary of Amazon’s leave policies. It is your responsibility to review the complete policy or policies related to the type(s) of leave you are taking. Leave policies are available on Inside Amazon and can also be obtained by calling Disability and Leave Services (DLS) at 1-888-892-7180 (Option 1, option 1 again). In the event of a conflict between this guide and the applicable leave policy, the terms of the policy will prevail. Please contact DLS if you have questions about your leave of absence.

This guide is also available on Inside Amazon and on Amazon Benefits: 

benefits.amazon.com (on the network)

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amazon.ehr.com (off the network)

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Medical-Related Benefits General Information Company-funded medical benefits may end based upon your leave type. If this occurs, you will have the option to continue benefits at your own expense (see section below on COBRA coverage).

If you combine different leave types, coverage may end sooner than indicated below. For example, if you take 12 weeks of FMLA leave followed by 12 weeks of Medical Leave or Personal Leave, coverage will cease at the end of the FMLA period.

If you have any questions about coverage during combined leaves, contact DLS at 1-888-892-7180 (Option 1). 

Short-Term Disability: Coverage will continue while on an approved Short-Term Disability (STD) claim. Coverage ends the first of the month following end of STD approval or 26 weeks, whichever occurs first. If your employment ends during STD, your benefit coverage may end.

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Family & Medical Leave Act (FMLA) Leave: Coverage ends the first of the month following 12 weeks of leave in a 12month period (26 weeks for FMLA military caregiver leave or combination of military caregiver and other FMLA-qualifying leave).

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State or Municipal Specific Leaves: Coverage will be maintained as specified by regulation. Contact DLS at 1-888-892-7180 (Option 1) for more information.

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Non-FMLA Medical Leave of Absence: Coverage ends the first of the month following 12 weeks of leave in a 12-month period, unless Non-FMLA Medical Leave immediately follows another leave.

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Personal Leave: Coverage ends the first of the month following 12 weeks of leave, unless Personal Leave immediately follows another leave.

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Military Leave: Coverage ends the first of the month following 12 weeks of leave.

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Pre- or Post-Partum Leave: Coverage will be maintained while on approved Parental Leave, and ends the first of the month following the end of leave

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Ramp Back: Coverage will be maintained at the full-time rate while on Ramp Back.

When approved for Short Term Disability (STD) (including Pre-Partum or Post-Partum) as part of your LOA, or Paid Parental Leave, any deductions for benefits will continue and be taken from your STD or Paid Parental Leave benefit.

If and when you stop receiving an Amazon paycheck while on leave (whether for working, paid time off, vacation, STD or Paid Parental Leave), you will be financially responsible for any continued premiums for medical coverage. During any unpaid leave, Amazon will pay premiums on your behalf, but you must repay these amounts when leave ends. When you return to work, benefit deductions will resume, with one additional deduction occurring each pay period until the amounts owed are repaid, as permitted by law. Please contact the Employee Resource Center (ERC) for more information about payroll deductions.

When you return to work, your benefit elections that had been in effect prior to your leave will automatically be reinstated effective the date of your return, unless you have elected to make changes while you were on leave during open enrollment or due to a qualifying event.

Contact the Benefits Service Center within 60 days of your qualifying event or within 30 days of your return to work if you decide you no longer want benefits coverage.

Provider/Contact: Benefits Service Center 1-866-644-2696 Note: In-house seasonal associates and part-time operations employees scheduled for 20-29 hours (Class M and Class Q) are ineligible for leave under Amazon leave policies. However, they may be eligible for leave under the Family and Medical Leave Act, leave as an accommodation under the Americans with Disabilities Act, or leave under an applicable state or local law. Seasonal and part-time associates should contact DLS at 1-888-892-7180 (Option 1) to determine how leave will be impact their benefits.

AMAZON_START COBRA Coverage: Medical, Dental, and Vision Coverage If your company-funded coverage ends, you and your covered dependents will be offered the option to continue your Medical, Dental, Vision and/or Health Care FSA coverage by electing and paying the full premium through COBRA. A COBRA packet will be mailed to your mailing address in PeoplePortal. Generally, you have 60 days from the date your benefits end to enroll in COBRA.

Changes to Benefits Related to Qualifying Events* If you experience a qualifying event* while on a benefits-eligible leave of absence, you have 60 days from the event date to make changes to your benefit elections. Any change must be consistent with your qualifying event. Call the Benefits Service Center.

Did you have a Qualified Status Change like Adoption or the birth of a child? Be sure to add coverage within 60 days of the Qualifying Event!

If you miss the deadline, you will not have the opportunity to make changes until the next Open Enrollment Period unless you have another qualifying event. *Qualifying events include birth or adoption of a child, marriage, divorce, gaining or losing group health coverage, death of dependent, etc.

Basic Life and Accidental Death and Dismemberment (AD&D) Insurance (company-paid) You may be eligible to convert your Basic Life Insurance coverage to an individual policy within 60 days of your coverage ending.

Prudential will mail out a conversion packet to your address on file if you are eligible within 60 days of your coverage ending.

You may not continue Basic AD&D coverage. If you choose to return with a “ramp back” schedule under the Ramp Back Policy, your Life and AD&D Insurance coverages are based on your full-time salary.

If you are approved for the Amazon short-term disability (STD) or long-term disability (LTD) Plan; your employer paid basic life and AD&D insurance coverage will continue and coverage will be based on your fulltime salary as of your last day worked.

In the event of an employee death, any enrolled dependents will receive the employee’s Amazon medical, dental and vision coverage at no cost for three months. After three months, dependents can enroll in COBRA.

Supplemental Life Insurance or Supplemental AD&D Insurance You may be eligible to convert your Supplemental Life Insurance (employee, spouse/domestic partner, and child) coverage to an individual policy within 60 days of your coverage ending. You may also have the option to convert or port your supplemental life insurance coverage to an individual policy if you are under age 70. Call Prudential within 60 days of your coverage ending.

You may not continue Supplemental AD&D coverage. If you are approved for the Amazon short-term or long-term disability plan; your supplemental life and/or AD&D insurance coverage will continue.

Resources for Living Resources for Living is mental health and wellness support available 24/7 to you at no cost. You, your family, and all members of your household have access to three free phone, video, or text therapy sessions per person, per issue, per year. You can also download the myStrength app (use access code: Amazon) for self-serve tools to manage stress, anxiety, depression, relationships, parenting and more.

Call a Care Partner at 1-833-721-2323 or register at ResourcesForLiving.com/Amazon.

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Bonuses, PTO, Stock & 401(k) Benefits, DSPP Sign-On Bonus This section applies to associates who were granted sign-on bonuses that have not been fully paid out at the time leave starts.

If you use paid time off (PTO) during your leave, you will continue to receive scheduled sign-on bonus payment(s) while you are on PTO. If you are taking Military Leave, Pre-Partum Leave or Post-Partum Leave, your sign-on bonus will continue to pay out and will not be suspended.

If you chose Ramp Back, your sign-on bonus will be pro-rated based on the Ramp Back percentage you elect. The sign-on bonus payout period will be extended by the pro-rated time of Ramp Back not worked.

If you return on a part-time basis, sign-on bonus payments may be pro-rated.

Except as stated above, Sign-on bonus payment(s) will be suspended (placed on hold) until your return to active employment status

Provider/Contact: ERC 1-888-892-7180

PTO, Vacation, and Attendance Policies PTO and Vacation Use During LOA If you will be on unpaid leave or partially paid leave (such as short-term disability leave), you may elect to have PTO apply during leave by notifying DLS.

Attendance Policies Employees in some lines of business are subject to attendance policies. If you apply for leave and miss work before your leave is approved, and your request is denied for any reason (e.g., ineligible, lack of certification, etc.), your absences could be subject to the applicable attendance policy. For example, under the North American Customer Fulfillment (NACF) Attendance Policy, the time may count against your Unpaid Time Off (UPT) balance.

PTO and Vacation Accrual Please review the policy that applies to your leave type(s) for information about accrual of Paid Time Off and Vacation Time during leave.

LOA Effect on Stock (RSU) Suspension and Cancellation of Vesting Vesting of your stock-based award may be suspended or your stock-based award may be cancelled due to a Leave of Absence.

Suspension of stock-based award vesting will result in vesting dates changing upon your Return to Work by the number of days you were on leave, minus any applicable grace period noted below. Cancellation of stock- based awards means that the award will cancel and will not be reinstated upon return to work. The following chart outlines the impact that different leave of absences could have on stock-based award vesting schedules. Unless otherwise required by law or noted below, vesting of stockbased awards will adjusted as follows:

Leave Type

Pay Circumstance

Personal Leave

Unpaid

Personal Leave

Using PTO

FMLA*, employee’s own illness FMLA*, employee’s own illness FMLA*, employee’s own illness Amazon Medical Leave, employee’s own illness Amazon Medical Leave, employee’s own illness Amazon Medical Leave, employee’s own illness ADA Leave as an Accommodation (LEA) )- employee’s own illness ADA Leave as an Accommodation (LEA) )- employee’s own illness ADA Leave as an Accommodation (LEA) )- employee’s own illness FMLA*, other reasons (care of family, etc.)

FMLA*, other reasons (care of family, etc.)

Pregnancy (pre- and post-partum)

RSU Suspension**

Cancellation

Suspension starts on 1st day No suspension during PTO period Suspension starts on 183rd day No suspension during PTO period Suspension starts on 183rd day

If PLOA exceeds 3 months If PLOA exceeds 3 months If combination of LOA exceeds 1 year If combination of LOA exceeds 1 year If combination of LOA exceeds 1 year

Paid by STD plan

Suspension starts on 183rd day

If combination of LOA exceeds 1 year

If leave exceeds 182 days

Using PTO

No suspension during If combination of PTO period LOA exceeds 1 year

If combination of LOA exceeds 1 year

Unpaid

Suspension starts on 183rd day

If combination of LOA exceeds 1 year

If leave exceeds 182 days

Paid by STD plan

Suspension starts on 183rd day

If combination of LOA exceeds 1 year

If leave exceeds 182 days

Using PTO

No suspension during If combination of PTO period LOA exceeds 1 year

If combination of LOA exceeds 1 year

Unpaid

Suspension starts on 183rd day

If combination of LOA exceeds 1 year

If leave exceeds 182 days

Using PTO

No suspension during If combination of PTO period LOA exceeds 1 year

If combination of LOA exceeds 1 year

Unpaid

Suspension starts on 15th day

If combination of LOA exceeds 1 year

If leave exceeds 14 days

Paid by STD plan

No suspension

If combination of LOA exceeds 1 year If combination of LOA exceeds 1 year

If combination of LOA exceeds 1 year If combination of LOA exceeds 1 year

Paid by STD plan Using PTO Unpaid

Paid Parental Leave Paid

No suspension

Compensation Impact*** Yes If PLOA exceeds 3 months If leave exceeds 182 days If combination of LOA exceeds 1 year If leave exceeds 182 days

Military Leave Military Leave Military Leave US SILOA-ATA Leave

Using Military Differential Pay (MDP) Using PTO Unpaid Unpaid

No suspension

No cancellation

No impact

No suspension

No cancellation

No impact

No suspension Suspension starts on 1st day

No cancellation If combination of LOA exceeds 1 year

No impact Yes

*Protected by any combination of FMLA, or state/local leave laws. ** If you are on a leave of absence for which vesting is suspended and transition to another type of leave of absence, vesting will remain suspended even if suspension would otherwise start on the 15th day of this subsequent type of leave of absence. ***In some circumstances, if the vesting schedule is paused or suspended, the vesting of your unvested stock-based awards may be moved into a new calendar year (January – December) or compensation year (April – March). Future annual compensation reviews will be based on the new vesting schedule that is established when you return from leave. Talk with your HRBP to understand how this might impact your annual compensation.

While on leave your stock vesting may show a placeholder year of 2099 or 2100, which will be updated upon your return from leave. When you return to active employment, your vesting schedule will be adjusted to reflect the number of days you were on leave (not including any period of PTO or applicable grace period).

While on Ramp Back, stock vesting will be pro-rated based on the Ramp Back option you have selected, and the remaining outstanding (unvested) stock-based awards (including RSUs) will be adjusted based on the number of days on Ramp Back.

Provider/Contact: 1-888-892-7180, option 1

Cancellation of Stock-Based Awards If Personal Leave exceeds 3 months, all of your outstanding (unvested) stock-based awards will be cancelled. Stock-based awards will be cancelled it you are employed by any non-Amazon entity during Personal Leave.

If collective leave time, together with other leaves of absence (other than military leave), including any paid personal time and vacation applied during the leaves, exceeds one continuous year, all of your outstanding stock-based awards will be cancelled on the first anniversary of the start date of the first leave.

For questions about stock during a leave of absence, call DLS at 1-888-892-7180, option 1

401(k) Account and 401(k) Loans Your Amazon 401(k) Savings Plan balance will remain invested while you are on leave, and you will continue to have the ability to access your account and change your investments.

While you are on leave, 401(k) deductions will be taken from eligible Amazon pay (note that STD benefit payments other than PrePartum and Post-Partum are not eligible pay).

If you have a 401(k) loan outstanding, loan payments will be withheld from your STD, Pre-Partum, Post-Partum or Paid Parental Leave benefit payments and processed into your 401(k) account to continue repayment of your loan. Please see the 401(k) Plan Loan Policy on Inside Amazon for additional information on paid, unpaid or military leaves of absence.

New 401(k) loans cannot be issued while you are on LOA. Provider/Contact: Fidelity 1-800-835-5095

Direct Stock Purchase Plan (DSPP) DSPP Deductions During LOA DSPP deductions do not change while on LOA. If you receive a paycheck and have net pay, you will have a DSPP deduction and purchase shares. If you have no pay while on LOA, then no deductions will be taken and no shares will be purchased.

Return to Work Position Reinstatement While on a LOA, your employment with Amazon is maintained, but reinstatement to your position is not guaranteed unless required by applicable law. Please review the policy or policies applicable to your leave type(s) for complete information about reinstatement following leave.

Absent certain exceptions (e.g., your position was eliminated during leave), reinstatement typically occurs as follows:    

FMLA, Pre-Partum, Post-Partum, Paid Parental Leave: Reinstatement to your prior position (or equivalent) is offered if you return to work on or before the end date of your approved leave.

Personal Leave: Reinstatement to prior or equivalent position is generally offered, but not guaranteed. Amazon has discretion to fill your position while you are on Personal Leave, and if this occurs, your employment will be terminated when your leave ends.

Military Leave: Reinstatement to prior position, or position that you would have been in had you not taken military leave, is offered.

Non-FMLA Medical Leave of Absence: Whether you will be reinstated, and to what position, will be determined on a caseby- case basis and consistent with applicable law

Reasonable Accommodation If you will require reasonable accommodation due to a disability or medical condition when you return to work, please contact 1-888892-7180, (Option 1), within two weeks prior to your return date if possible. Amazon will engage in an interactive process with you to discuss how to support your limitations or restrictions and any specific accommodation details. More information on the Amazon’s reasonable accommodation policy is available at Inside Amazon.

Provider/Contact: Your HR Partner

Important Provider Contact Information Provider

Contact Information

Availability

Disability and Leave Services (DLS)

 

1-888-892-7180, option 1, https://dls.idp.amazon-corp.com (on the network), or via A to Z under the Time-Off tab

 

Employee Resource Center (ERC)



1-888-892-7180

24/7

Benefits Service Center



1-866-644-2696

Monday – Friday 5 a.m. – 6 p.m. PT

Amazon Benefits



benefits.amazon.com (on the network) amazon.ehr.com (off the network)

24/7



Intake (new cases): 24/7 Case Management: Monday – Friday, 5 a.m. – 5 p.m. PT

Amazon Stock Portal



amazonstock.com (on the network), or via A to Z under Resources tab

24/7

Fidelity Stock Plan



1-800-544-9354 www.netbenefits.com

Monday – Friday, 8:30-8:30 EST



Morgan Stanley Stock Plan Connect

 

1-833-721-2323 stockplanconnect.com

Monday – Friday, 5 a.m. – 5 p.m. PT

Resources for Living (Employee Assistance Program)

 

1-833-721-2323 resourcesforliving.com/amazon

24/7

Aetna

 

1-866-574-9124 amazon.aetna.com

24/7

Premera Blue Cross

 

1-877-995-2696 premera.com/amazon

24/7

Kaiser Permanente

 

1-855-249-5008 my.kp.org/amazon

24/7

Express-Scripts

 

1-844-626-9387 Express-scripts.com/amazon

24/7

RxAdvance (CT, DE, FL, IN, KS, NC, NV, PA)

 

1-800-991-3164 amazon.rxacloud.com

24/7

Delta Dental

1-844-466-8847 Deltadentalwa.com

Monday – Friday 7 a.m. – 5 p.m. PT

  

1-844-401-5670 vsp.com



Prudential



1-855-778-3291

Monday – Friday, 5 a.m. – 5 p.m. PT

Fidelity HSA



1-800-835-5095 netbenefits.com/amazon

Monday – Friday 8:30 a.m. EST – 12 a.m. EST

Optum Financial (FSA)

 

1-855-609-8616 Connectyourcare.com

24/7

COBRA Connect

 

1-877-29-COBRA (26272) cobra.ehr.com

Monday – Friday, 6 a.m. – 4 p.m. PT

Grand Rounds

 

1-800-510-7990 grandrounds.com/amazon

24/7

My 401(k) Fidelity

 

1-800-835-5095 (Amazon 401(k) Plan number: 093958)

Monday – Friday, 8:30 a.m. – 8:30 p.m. PT

Computershare

 

1-866-239-0172 computershare.com/amazon

Monday – Friday, 12 a.m. – 6 p.m. PT

CastLight



1-800536-8707

Monday – Friday, 5 a.m.– 6 p.m. PT

VSP





Monday - Friday 5 a.m. to 6 p.m., Pacific Time Saturday & Sunday 7 a.m. to 5 p.m., Pacific Time

AMAZON_START

Return Fax Cover Sheet Return Fax Number: 1-855-579-1799 Employee:

Phone:

Case Number:

Comments:

If you have any questions or concerns, please contact Disability & Leave Services (DLS) by emailing amazondls@amazon.com or calling (888)892-7180.

NOTE: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers from requesting or requiring genetic information of employees or their family members. Please do not provide any genetic information when responding to this request for medical information. Genetic information is defined in 29 CFR. § 1635.3.

Do not provide information about genetic tests, as defined in 29 C.F.R. § 1635.3(f), genetic services, as defined in 29 C.F.R. § 1635.3(e), or the manifestation of disease or disorder in the employee’s family members, 29 C.F.R. § 1635.3(b).

AMAZON_START

Authorization to Obtain and Disclose Information  Instructions for Employee: Complete and return to Amazon Disability & Leave Services (DLS).  Return the form: Upload the completed form to the DLS Portal, found on the Amazon AtoZ Resources page or at dls.idp.amazon-corp.com (while on the Amazon network). You can also email to amazondls@amazon.com or fax to 1-855-579-1799.

Employee Name: Ziping Liu

Employee Date of Birth: January 28, 1995

Employee ID: 106181148

This Authorization is being provided so that Amazon and any of its parents, affiliates, subsidiaries, and/or third-party contractors; Aetna Inc. (Aetna), and any of their parents, affiliates, subsidiaries, and/or third-party contractors; The Hartford, and any of their parents, affiliates, subsidiaries, and/or third-party contractors; Amazon Corporate LLC (together with any of its Affiliates or Subsidiaries (Amazon); WorkCare, and any of its parents, affiliates, subsidiaries, and/or third-party contractors; and/or Sedgwick Claims Management Services, Inc. (Sedgwick CMS) can obtain the necessary information to adjudicate a claim for disability or workers’ compensation benefits, or a request for leave of absence or related benefits, initiated by or on behalf of the Patient identified above (“Patient”). Once this Authorization is completed and signed by the Patient (or Patient’s guardian) whose personal health information is to be disclosed, the health care provider should retain the original for its records and provide a copy of the Authorization to the Patient.

Patient can submit completed document via the DLS Portal, by faxing to 1-855-579-1799, by emailing amazondls@amazon.com, or by mail to Amazon Disability & Leave Services (DLS), PO Box # 81103 Address: 5801 Postal Road, Cleveland, Ohio 44181.

To: Any health care provider, Pharmacy Benefit Manager, employer, benefit plan, insurer, financial institution, consumer reporting agency, educational institution, or federal, state, or local government agency, including the Social Security Administration and Veterans’ Administration.

By signing the Patient Authorization below, your Patient has authorized you to disclose to Amazon, Aetna, The Hartford, WorkCare, or Sedgwick CMS a complete copy of any and all personal or privileged information, records, or documents described herein.

Information covered by this authorization: Any and all medical (but not genetic) information or records, including X-ray films, prescription histories, medical histories, physical, mental or diagnostic examinations, and treatment notes, and including information regarding HIV/AIDS, communicable diseases, alcohol or drug abuse, and mental health, as such information may be related to the Patient’s claim for benefits; work information and history, including job duties, earnings and personnel records, and client lists; information on any insurance coverage and claims filed, including all records and information related to such coverage and claims; Social Security benefits information, including monthly benefit amounts, monthly payment amounts, entitlement dates, and information from my Master Beneficiary Record.

The information obtained by use of this Authorization will be used to evaluate and administer the Patient’s claim for benefits under the employer’s plan for short-term disability benefits or long-term disability benefits insured by Aetna or The Hartford, to administer the Patient’s claim for workers’ compensation benefits, and/or a request for leave of absence or related benefits. Such information is referred to in the Patient Authorization as “My Information.”

PATIENT AUTHORIZATION I authorize Amazon, Aetna, The Hartford, WorkCare, or Sedgwick CMS to use or disclose My Information as necessary to administer my claim for short-term disability benefits and/or workers’ compensation benefits and/or leave of absence or related benefits. I also authorize Amazon, Aetna, The Hartford, WorkCare, or Sedgwick CMS to disclose My Information as follows: (i) to Amazon for (a) functions related to accommodating my medical restrictions or limitations;

(b) federal or state Family & Medical Leave Act administration; (c) administration of related leave or benefits claims;(d)fulfilling fiduciary obligations under my benefit plan or (e) responding to legal claims against Amazon or its agent; (ii) to the administrator or other service providers of Amazon’s benefit plan or other benefit plans of my employer for plan-related functions; (iii) to any system used for claims processing or insurance broker to carry out functions related to my benefit plan or claim; (iv) to any health care professional who has treated or evaluated me or who may do so; (v) to other persons or entities performing business or legal services related my claim or to other benefits for which I may be eligible in the future; (vi) as may be lawfully required; (vii) as I may further authorize; or (viii) as necessary to prevent or to detect perpetration of a fraud in connection with my application for benefits.

I authorize the disclosure of my personal and medical information as described above. I understand that this authorization is voluntary. I understand that information disclosed pursuant to this Authorization may be subject to redisclosure by the recipient as permitted by applicable law or my further authorization. I understand that I have the right to fully or partially revoke this Authorization for future disclosures from Amazon, Aetna, WorkCare, or Sedgwick CMS may make, unless they have taken action in reliance upon this Authorization. If I decide to fully or partially revoke my Authorization, I must revoke do so in writing directly to Amazon, specifying whether I wish to fully revoke my authorization, or, if I wish to partially revoke my authorization, providing a description of the information and/or purposes for which I am withdrawing my authorization. I understand that my medical treatment, payment for medical benefits, or enrollment/eligibility for leave benefits cannot be conditioned on my allowing Amazon, Aetna, the Hartford, WorkCare, or Sedgwick CMS to re-disclose My Information and that I may fully or partially revoke my authorization for re-disclosure at any time.

This Authorization expires two years from the date listed below or earlier as required by law, or upon my revocation, if earlier, but will not exceed the term of my coverage of the policy or benefit plan. I understand that I am entitled to receive a copy of this Authorization upon request. A photocopy or facsimile of this Authorization shall be as valid as the original. If there is a conflict between a prior request for restriction on the disclosure of My Information and this Authorization, this Authorization will control.

Note to employee/beneficiary: In order to be considered for short-term disability or workers’ compensation benefits, you must authorize disclosure of personal and medical information as needed to determine whether you qualify for those benefits. If signed, this form would also authorize further disclosure of your information in order to expedite consideration of your eligibility for additional benefits in the future. Such additional benefits might include long-term disability benefits, vocational rehabilitation services, and payment of life insurance premium while you are on leave. You are not required to authorize disclosure or re-disclosure of your personal or medical information for such additional purposes. If you do not want this release to authorize such additional disclosure, please contact DLS at 1-888-892-7180.

Important Information for Your Health Care Provider About GINA The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. "Genetic Information" as defined by GINA includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

______________________________

_____________________________________

Signature of Patient or Guardian

Relationship to Patient (if signed by guardian)

_______________ Date Signed

AMAZON_START

Paid Family and Medical Leave Statement of Employee Rights You may qualify for Paid Family and Medical Leave

As of Jan. 1, 2020, Washington employees who have worked 820 hours or more in the qualifying period and experience(d) a qualifying event have access to Paid Family and Medical Leave.

Employees who have missed work due to family or medical reasons may be eligible for paid family or medical leave for the following qualifications:   

Care for and bond with a child younger than 18 following birth or placement Care for yourself or a family member experiencing a serious health condition Certain military-connected events.

Paid Family and Medical Leave requires that you give your employer(s) written notice at least 30 days in advance of when you plan to take leave. However, if the reason you need leave was not foreseeable, you may notify your employer(s) as soon as possible.

The Paid Family and Medical Leave Benefit Guide provides information on how to apply for benefits and submit weekly claims. It also explains your rights and responsibilities under the law. Download the guide at www.paidleave.wa.gov/benefit-guide.

For more information about how to apply, contact us at 833-717-2273 or visit www.paidleave.wa.gov.

Important information for when you apply

Employer UBI #: 602-201-545 This employer offers supplemental benefits: Yes, which includes: Short-Term Disability (STD), Pre-Partum Disability Leave, Post-Partum Disability Leave, and Parental Leave. Paid Time Off, Vacation and Sick Time are not offered as supplemental benefits to the benefits from the state.

Note: Except during the waiting week, employees cannot use employer provided paid time off at the same time as Paid Family and Medical Leave, unless the employer chooses to offer a “supplemental benefit.” Supplemental benefits can be used along with Paid Family and Medical Leave to provide additional pay while an employee receives partial wage replacement through Paid Leave benefits. Employees may accept or reject supplemental benefit payments.

EMPLOYER NOTICE TO EMPLOYEE UPDATED NOVEMBER 2019

Page 1 of 1

AMAZON_START

Dear Treating Provider, Your patient has requested an absence from work, and disability benefits related to their own illness or injury. In order to accurately assess your patient’s functional status and eligibility for disability benefits, the following information is required. In completing this form, we ask that you:  Provide answers and best estimates based on your medical knowledge, experience, and assessment of the patient.  Provide relevant ICD 10 and CPT code to help expedite your patient’s absence case decision.  Provide information as specific as possible. Terms such as “unable to determine,” or “as needed” may not be sufficient to approve a request for FMLA, and disability leave and paid benefits.  Along with the completed form, please provide Office/Progress Notes or other relevant Medical Records If a covered entity uses language such as the following, any receipt of genetic information in response to the request for medical information will be deemed inadvertent: “The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Return the completed form and any other medical records by: Fax #: 1-855-579-1799, or Email: amazondls@amazon.com

SFDC: 5004o00000P6BuiAAF E106 vs 10.18 04073256

Physician Statement Patient Name: Ziping Liu Patient Job Title: Software Development Engineer Requested Leave Start Date: March 30, 2022 Physical Demand: Regular Full Time

Patient Date of Birth: January 28, 1995 Case Number: 04073256 Requested Return To Work: April 16, 2022

1. Diagnostic Information Primary Disabling Diagnosis: Secondary Diagnosis:

ICD-10: ICD-10:

Onset Date: / /

Surgery Name: CPT: Date of Surgery: Type of Surgery:  Open  Minimally Invasive / / • Is the patient’s primary condition due to injury or illness arising out of the patient’s employment?  No  Yes • Is this absence from work related to patient’s pregnancy, or recovery from childbirth or pregnancy loss?  No  Yes, with due date or with actual delivery date / /  Vaginal delivery  Cesarean

2. Treatment Information • Office visits: Most recent visit date: / / Next visit: / / • If Hospitalized, Admitted on: / / Discharged on: / / • Treatment plan & Medication(s) for Primary Disabling Diagnosis - name /dosage/last titrated: ______________________ • If Patient referred to specialist, Providers Name _________________ Specialty ______________ Phone __________ 3. Clinical and Functional Assessment Do you consider your patient to be totally impaired from working?  No  Yes If yes, as of what date? / / , with an actual / expected return to work date of / / If yes, as supported by the following rationale from their Last office visit on ----/____/_______(citing medical facts documenting patient’s functional impairments, physical and diagnostic exam findings, your assessment, restrictions, if applicable formal Mental Status Exam findings).

4. Return to Work Planning What is the estimated date of the patient’s release to modified duty

/

/

and to full duty

/

/

Are there any temporary work restrictions and/or accommodations which would allow your patient to return to work?  No  Yes, If Yes please specify by providing objective quantification e.g. no lifting greater than 20 lbs. _________________________________________________________________________________________ _________________________________________________________________________________________ 5. Providers Certification (I certify that the information contained on this form and submitted with this form is true and correct.)

Provider’s Name and Credentials (MD, DO, etc.)

Signature

Specialty

Date

Phone

Fax