Free form template · Word

Medical Leave Application

A medical leave application form is used for longer absence due to hospitalisation, surgery, accident or prolonged illness. Compared with a simple sick leave letter, it captures treating doctor details, certificates, the leave heads to be used and the fitness certificate needed to rejoin.

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[Company Logo][Company Name]

MEDICAL LEAVE APPLICATION FORM

Company:: [Company Name]
Form No.:: [Reference Number]
Date:: [Date]

1. Employee Details

Employee Name	[Employee Name]
Employee ID	[Employee ID]
Designation / Department	[Designation] / [Department]
Reporting Manager	[Reporting Manager]

2. Reason for Medical Leave

[ ] Hospitalisation [ ] Planned surgery [ ] Prolonged illness [ ] Accident (outside work) [ ] Injury at work – Accident Report No. [Reference Number]
Brief description (no detailed diagnosis needed)
Treating doctor / hospital name and city
Date of admission / start of illness	[DD/MM/YYYY]

3. Leave Period and Leave Heads

Leave Head	From	To	Days
Sick Leave	[DD/MM/YYYY]	[DD/MM/YYYY]	[Number]
Earned Leave	[DD/MM/YYYY]	[DD/MM/YYYY]	[Number]
Leave Without Pay	[DD/MM/YYYY]	[DD/MM/YYYY]	[Number]

4. Documents

Medical certificate stating the period of rest
Discharge summary (if hospitalised)
Insurance / TPA claim number or ESI reference: [Reference Number]
Fitness certificate to be submitted before rejoining

5. Contact During Leave

Contact number
Alternate contact (family member) and relationship

Declaration: I certify that the above information is true. I will submit the required medical documents and a fitness certificate before resuming duty, and will inform HR if my recovery period changes.

Employee / Family Member on behalf
[Employee Name]
Date: [Date]

6. For HR

Documents verified	[ ] Yes [ ] Pending
Leave sanctioned as per table above	[ ] Yes [ ] Modified – [Details]
Expected date of rejoining	[DD/MM/YYYY]

Reporting Manager
[Reporting Manager]

HR
[HR Name]

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What this template includes

Nature of absence (hospitalisation, surgery, illness) without unnecessary diagnosis
Treating doctor or hospital details for verification
Certificate checklist including fitness certificate on return
Leave heads in order of debit
Insurance or ESI claim reference
Emergency contact while on leave

When to use it

Planned surgery or a hospital stay
Illness expected to last more than the short sick leave threshold
Recovery after an accident, including a workplace injury
Medical absence that needs several leave heads (SL, EL, LWP) combined

How to customise this template

1Decide the order in which leave heads are debited, as per policy
2Add your group medical insurance TPA contact
3Add the ESI branch details for ESI-covered staff
4Mark the section on workplace injury if the leave arises from an accident at work

HR tips

Keep medical documents in a confidential file with restricted access
Ask for a fitness certificate before return from long medical leave, especially for safety-critical roles
Report workplace injuries through the proper accident reporting process as well
Check in with the employee kindly, without pressure to return early

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Frequently asked questions

What is the difference between sick leave and medical leave?+

Many companies use the terms interchangeably. Where they differ, sick leave covers short illness, while medical leave covers longer absences such as hospitalisation or surgery, often needing more documentation.

What documents are needed for medical leave?+

Usually a medical certificate from the treating doctor stating the period of rest, discharge summary if hospitalised, and a fitness certificate before rejoining.

Can I use earned leave for medical reasons?+

Yes. When sick leave is exhausted, most policies allow earned leave to be used for medical absence, followed by leave without pay.

All 50 leave management →

[Company Logo][Company Name]

LEAVE APPLICATION FORM

Company:: [Company Name]
Form No.:: [Reference Number]
Date of Application:: [Date]

Part A – Employee Details

Employee Name
Employee ID
Designation
Department
Reporting Manager
Work Location
Mobile Number

Part B – Leave Details

Type of Leave	[ ] Casual [ ] Sick [ ] Earned/Privilege [ ] Compensatory Off [ ] Leave Without Pay [ ] Other: [Specify]
From Date (DD/MM/YYYY)
To Date (DD/MM/YYYY)
Number of Working Days
Half Day	[ ] First Half [ ] Second Half [ ] Not Applicable
Reason for Leave
Address and Phone Number During Leave

Part C – Work Handover

Form · Word

Leave Application Form

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[Company Logo][Company Name]
CASUAL LEAVE APPLICATION
Date:
[Date]
To,
[Reporting Manager]
[Designation]
[Department]
[Company Name], [Work Location]
Subject: Application for Casual Leave on [DD/MM/YYYY] [to DD/MM/YYYY]
Dear Sir / Madam,
I request casual leave for [Number] day(s) on [DD/MM/YYYY] [to DD/MM/YYYY] to attend to [a personal matter / a family function / documentation work at a government office].
I have completed or handed over my pending work as follows:
Letter · Word
Casual Leave Application
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[Company Logo][Company Name]
SICK LEAVE APPLICATION
Date:
[Date]
To,
[Reporting Manager]
[Department]
[Company Name]
Subject: Application for Sick Leave from [DD/MM/YYYY] to [DD/MM/YYYY]
Dear [Reporting Manager],
I was unwell with [fever / viral infection / a medical condition] from [DD/MM/YYYY] and, on the advice of my doctor, was unable to attend office. I had informed you by [phone / message / email] on [DD/MM/YYYY] at [Time].
I request that my absence from [DD/MM/YYYY] to [DD/MM/YYYY], a total of [Number] working days, be treated as sick leave.
Letter · Word
Sick Leave Application
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[Company Logo][Company Name]
EARNED LEAVE APPLICATION
Date:
[Date]
To,
[Reporting Manager]
[Designation]
[Company Name]

Through: HR Department
Subject: Application for Earned Leave from [DD/MM/YYYY] to [DD/MM/YYYY]
Dear [Reporting Manager],
I wish to apply for earned leave of [Number] days from [DD/MM/YYYY] to [DD/MM/YYYY] for [a family vacation / a visit to my native place / personal commitments]. I request permission to [prefix / suffix] the holiday / weekly off on [DD/MM/YYYY] to this leave, as permitted under the leave policy.
Particulars Details
Earned leave balance as on date [Number] days
Leave applied [Number] days
Balance after leave [Number] days
Date of rejoining [DD/MM/YYYY]
Letter · Word
Earned Leave Application
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Particulars	Details
Earned leave balance as on date	[Number] days
Leave applied	[Number] days
Balance after leave	[Number] days
Date of rejoining	[DD/MM/YYYY]

[Company Logo][Company Name]

PRIVILEGE LEAVE APPLICATION FORM

Establishment:: [Company Name]
Unit / Plant:: [Work Location]
Application No.:: [Reference Number]
Date:: [Date]

A. Worker / Employee Details

Name	[Employee Name]
Token / Employee No.	[Employee ID]
Department / Section	[Department]
Designation / Grade	[Designation]
Shift	[ ] General [ ] A [ ] B [ ] C
Date of Joining	[Date of Joining]

B. Leave Applied

Period: From [DD/MM/YYYY] To [DD/MM/YYYY]
Number of days	[Number]
Holidays / weekly offs falling within the period	[Dates]
Purpose	[Purpose]
Address during leave	[Address]
Advance wages requested	[ ] Yes [ ] No

I request privilege leave for the above period. I will report for duty in my shift on [DD/MM/YYYY].

Form · Word

Privilege Leave Application

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[Company Logo][Company Name]
APPLICATION FOR PAID LEAVE
Date:
[Date]
To,
The HR Department
[Company Name]
[Company Address]

Copy: [Reporting Manager]
Subject: Request for Paid Leave from [DD/MM/YYYY] to [DD/MM/YYYY]
Dear Sir / Madam,
I request paid leave of [Number] working days from [DD/MM/YYYY] to [DD/MM/YYYY] for [personal reasons / travel / family commitments]. As per my latest leave statement, my available paid leave balance is [Number] days.
I request that this leave be processed with full pay for the month of [Month, Year]. In case my balance is found to be insufficient, please:
Letter · Word
Paid Leave Application
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[Company Logo][Company Name]
APPLICATION FOR LEAVE WITHOUT PAY
Date:
[Date]
To,
[Reporting Manager]
[Department], [Company Name]

Copy: HR Department
Subject: Request for Leave Without Pay from [DD/MM/YYYY] to [DD/MM/YYYY]
Dear [Reporting Manager],
I request leave without pay for [Number] days from [DD/MM/YYYY] to [DD/MM/YYYY]. I need this time because [brief reason, e.g. care of a family member / completion of a personal legal matter / relocation of my family].
I have checked my leave balances and confirm that my casual, sick and earned leave are [exhausted / not sufficient for this period]: CL [Number], SL [Number], EL [Number].
Letter · Word
Unpaid Leave Application
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[Company Logo][Company Name]
APPLICATION FOR MATERNITY LEAVE
Date:
[Date]
To,
The HR Manager
[Company Name]
[Company Address]

Copy: [Reporting Manager]
Subject: Application for Maternity Leave
Dear [HR Name],
I am pleased to inform you that I am expecting a child, and my expected date of delivery is [DD/MM/YYYY], as per the enclosed certificate from [Doctor Name / Hospital Name].
I request maternity leave from [DD/MM/YYYY] to [DD/MM/YYYY], a total of [Number] weeks, in accordance with the maternity benefit provisions applicable to me and the company policy. Of this, I propose to take [Number] weeks before the expected date of delivery and the balance after delivery.
Letter · Word
Maternity Leave Application
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Medical Leave Application

Preview of the form

1. Employee Details

2. Reason for Medical Leave

3. Leave Period and Leave Heads

4. Documents

5. Contact During Leave

6. For HR

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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