October 14, 2022

SCOTT HAZLE
3535 NE 45TH AVE
PORTLAND OR 97213

Dear Scott,

Thank you for contacting American Family Life Assurance Company of Columbus (Aflac). We will be
managing your leave of absence on behalf of Columbia Sportswear Company. This letter confirms
that we have opened a case on your behalf, provides an overview of the leave(s) that apply to your
request, and outlines the next steps. This also serves as your notice of our review of your eligibility for job
protection under the federal Family and Medical Leave Act (FMLA).

Your case summary:

Please confirm the information we have for your case. If any of the information below is incorrect, has
changed or if you have questions; please contact us right away at (800) 206-8826. To cancel your case,
call us or send us a written request.

Case #: 00442177
Type: Intermittent
First date absent: August 12, 2022
FMLA time considered: August 12, 2022 - February 12, 2023
Reason: Employees Own Illness or Injury

Your leave summary:

Based on your case summary, we’re in the process of reviewing your eligibility for the following leave(s):

·You have met the eligibility requirements to take this leave.

·a 12-month
Federal FMLA
FMLA offers up to 12 workweeks of unpaid job protected leave in
period. FMLA time available is measured backward
12 months from the date of your first FMLA leave usage. This is
called a roll-back period.
·If approved, this time away from work will be counted as an FMLA
leave.
·FMLA may also run at the same time as other leave programs.
·You may take FMLA leave when you are unable to work because
of your own serious health condition.
·To get more information about the federal Family and Medical
Leave Act (FMLA), you can refer to the attached Employee
Rights Under the Family and Medical Leave Act, or go online to
www.dol.gov/agencies/whd/fmla.

·You have met the eligibility requirements to take this leave.

·year. Anallows
Oregon Family
Oregon eligible employees to take up to 12 weeks per
additional 12 weeks per year is available to care for the

Page 1
 employee's ill or injured child who does not have a serious health
condition but who requires home care.

If you need additional time, please contact us right away. You must also notify your manager of your
intent to take additional time.

Next steps:

It's important that we receive the information we're asking for by October 16, 2022. If incomplete
information is provided or we receive it late, your leave may be delayed or denied. This means you may
not have job protection and your absence will be subject to your Company’s normal attendance policies
Changes to your case may affect our decision. Letting us know right away can avoid any delays.

Forms to be Completed:

Authorization to Collect and Disclose Information

This will give us permission to obtain information on your behalf to support your claim. We have included
the form for you to complete or you can log into our portal at https://mygrouplifedisability.aflac.com/
personal/s/login and electronically sign the Authorization to Collect and Disclose Information form.

Health Care Provider Certification of Medical Leave

Have your treating provider(s) complete this form. We’ll use this form to make a decision on your job
protection under state and federal leave laws including the FMLA (if eligible).

Form(s) you may need to complete:

Third-Party Authorization
Complete this form if you want to authorize someone to have access to your case information and speak
to us on your behalf. If you do not want to authorize anyone, there is no need to fill out the form.

How to send us forms and information:

You have the following options on how you can send us forms and information that we need:

·Take a photo or scan and upload it in to your case at https://mygrouplifedisability.aflac.com/

personal/s/login or
·Fax to (800) 206-9472 or
·Mail can
You email it to us at myPLADSleave@aflac.com or
· it to us at: Administrative Office
PO Box 8307
Columbus GA 31908-8307

Please include the case number on the document(s) being sent to us.

Reporting your intermittent time:

When you need to report an absence for this leave request, you're required to report your absence to us
within two days of returning to work. You must also contact your manager to let them know that you will
be taking approved time off.

You can report your time off to us by visiting our portal at https://mygrouplifedisability.aflac.com/personal/
s/login. From your Dashboard page, select your Intermittent case (# 00442177). From the Things you

Page 2
can do button, select the Add Time option and enter your time off. You can also contact our interactive
voice response (IVR) system at (800) 206-8826 and follow the prompts to report your time.

Additional information from CSC:

Life Events: If you have a benefit life event (birth of child, adoption, marriage, divorce, or gain/loss of
insurance coverage), notify CSC within 30 days of that benefit life event and provide the appropriate
documentation in Workday. If you need any assistance, please reach out to askhr@columbia.com.

When on leave: Time off during a leave that is not paid by Aflac will be paid to the employee using
available accrual balances, such as PTO, Floating Holiday, etc. If you are on a parental leave, you could
qualify for Paid Parental Leave pay. Employees in California may ask for a waiver from using PTO or
other Company paid time off during their leave. Contact AskHR to request a waiver.

Additional benefits: CSC offers other great benefits to assist you. We have an enhanced Employee
Assistance Program (EAP), which provides 6 visits per year for behavioral health, as well as parental
resources, financial coaching, legal services, ID theft protection, fertility resources, mindfulness/relaxation
tools, and much more. Additionally, we have family planning and parenting programs as well as daycare
discounts and a pre-tax dependent care flexible spending account.

Looking for more information?

Our portal allows you to check the status of your case, report hours, upload documents and manage
your communication preferences including text notification. Go to https://mygrouplifedisability.aflac.com/
personal/s/login to login using your unique username and password. Use Google Chrome to ensure you
get the best experience on our portal.

Managing your communication preferences:

In the Aflac portal, go to your profile page and click on the Notifications tab:

·Toclickupdate
Save.
your Communication Preferences, click blue edit tool, select US Mail or Email and

·ToSave.update your Text Messaging Preferences, click blue edit tool, follow the prompts and click
Our Customer Care Advocates are also eager to help answer any questions you may have. You can
contact them at (800) 206-8826 from 8:00 am to 8:00 pm EST.

Sincerely,

Gersen L.
.
Premier Life, Absence and Disability Solutions | Aflac Group Insurance *

Enclosures:

Employee Rights Under the Family and Medical Leave Act

Authorization to Collect and Disclose Information
Health Care Provider Certification of Medical Leave
Third Party Authorization
*Absence Management Services are administered by Continental American Insurance Company and its affiliates

Page 3
EMPLOYEE RIGHTS
UNDER THE FAMILY AND MEDICAL LEAVE ACT
THE UNITED STATES DEPARTMENT OF LABOR WAGE AND HOUR DIVISION

LEAVE Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period
ENTITLEMENTS for the following reasons:

x The birth of a child or placement of a child for adoption or foster care;

x To bond with a child (leave must be taken within 1 year of the child’s birth or placement);
x To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;
x For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job;
x For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse,
child, or parent.
An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks
of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness.

An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees
may take leave intermittently or on a reduced schedule.

Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee
substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.

BENEFITS & While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave.
PROTECTIONS Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with
HTXLYDOHQWSD\EHQHÀWVDQGRWKHUHPSOR\PHQWWHUPVDQGFRQGLWLRQV

An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave,
opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.

ELIGIBILITY An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must:
REQUIREMENTS x Have worked for the employer for at least 12 months;
x Have at least 1,250 hours of service in the 12 months before taking leave;* and
x Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite.
6SHFLDO´KRXUVRIVHUYLFHµUHTXLUHPHQWVDSSO\WRDLUOLQHÁLJKWFUHZHPSOR\HHV

REQUESTING Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice,
an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures.
LEAVE
Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine
LIWKHOHDYHTXDOLÀHVIRU)0/$SURWHFWLRQ6XIÀFLHQWLQIRUPDWLRQFRXOGLQFOXGHLQIRUPLQJDQHPSOR\HUWKDWWKHHPSOR\HHLVRU
will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or
continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which
)0/$OHDYHZDVSUHYLRXVO\WDNHQRUFHUWLÀHG

(PSOR\HUVFDQUHTXLUHDFHUWLÀFDWLRQRUSHULRGLFUHFHUWLÀFDWLRQVXSSRUWLQJWKHQHHGIRUOHDYH,IWKHHPSOR\HUGHWHUPLQHVWKDWWKH
FHUWLÀFDWLRQLVLQFRPSOHWHLWPXVWSURYLGHDZULWWHQQRWLFHLQGLFDWLQJZKDWDGGLWLRQDOLQIRUPDWLRQLVUHTXLUHG

EMPLOYER Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the
RESPONSIBILITIES employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and
responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility.

Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as
FMLA leave.

ENFORCEMENT (PSOR\HHVPD\ÀOHDFRPSODLQWZLWKWKH86'HSDUWPHQWRI/DERU:DJHDQG+RXU'LYLVLRQRUPD\EULQJDSULYDWHODZVXLW
against an employer.

The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective
bargaining agreement that provides greater family or medical leave rights.

For additional information or to file a complaint:

1-866-4-USWAGE
(1-866-487-9243) TTY: 1-877-889-5627

www.dol.gov/whd
U.S. Department of Labor Wage and Hour Division

WH1420 REV 04/16

Authorization to Collect
and Disclose Information

Administrative Office Toll Free:(800) 206-8826

PO Box 8307 Fax: (800) 206-9472
Columbus GA 31908-8307 Email: myPLADSleave@aflac.com

Name: Case Number: Date of Birth:

Scott Hazle 00442177 {{Dte1_es_:date}}

This authorization is designed to comply with the Health Insurance Portability and Accountability Act of
1996 ("HIPAA").

I authorize the following parties: employers or their agents, health plans, health care providers or
other medically related facilities, pharmacies, pharmacy benefit managers, clearinghouses,
rehabilitation professionals, insurance companies, reinsurers, health maintenance organizations, third
party administrators, employee assistance programs, insurance support organizations, government
organizations or agencies, the Social Security Administration, the Internal Revenue Service, social
security disability advocates or representatives, financial institutions, accountants or tax preparers,
business entities, and educational institutions.

To disclose to Aflac 1 or Aflac’s1 representative (whether by written, telephonic or electronic means)

the following information about me for the purpose of administering and evaluating my claim,
including return to work assistance:

(1) medical information: the entire medical record, prescription drug history, and any other health
or billing information, including information regarding HIV, sexually transmitted diseases,
mental illness, use of alcohol, drugs, and tobacco, any and all information regarding the
diagnosis, treatment or care of any physical or mental condition with the exception of
psychotherapy notes; and
(2) financial information: income or benefits from any source, entitlement dates, Social Security
Administration Master Beneficiary Record information, financial reports, professional licenses,
insurance claims and benefits, earnings or payroll records, employment history (collectively "My
Information").

I understand that My Information disclosed to Aflac1 pursuant to this Authorization may no longer be
covered by HIPAA rules governing privacy, but other privacy laws will continue to apply. Aflac1 may
disclose My Information as may be otherwise lawfully required, or as I may further authorize, or as may
be necessary to prevent and detect fraud.

1
Aflac means Continental American Insurance Company or American Family Life Assurance Company of NY,
or American Family Life Assurance Company of Columbus.

Page 1 of 2
Authorization to Collect and Disclose Information

Full Name: Case Number:

Scott Hazle 00442177

I further authorize Aflac1 to disclose My Information for the purpose of (1) carrying out
administration, (2) auditing, (3) claim payment, (4) health care operations, by or to the following
parties: any employee benefit plan sponsored by my employer; any party providing services or
insurance benefits to or for my employer’s plan or claim; any party providing or performing services to
or for Aflac1; any benefit offered by Aflac1 and its insuring affiliates; or Social Security Administration.
Payment will not be conditioned on whether I authorize Aflac to disclose My Information as described
in this paragraph.

This Authorization will remain in force for one year or for the length of time otherwise permitted by
law. I understand that I am entitled to receive a signed copy of this Authorization. A paper, electronic,
or photographic copy of this Authorization is as valid as the original.

I understand that I have the right to revoke this Authorization in writing at any time by providing
written notice to Aflac1 at the address above. I understand that a revocation is not effective to the
extent that Aflac1 has already received or disclosed information in reliance on this Authorization. If I
choose not to give the Authorization, alter, or if I later revoke, I understand Aflac1 may not be able to
determine if benefits are payable.

By signing below, I am indicating that I am authorized to sign,

{{[]}} By checking this box and providing my electronic signature below, I am indicating that I intend

to sign this authorization form electronically, and I consent to receive an electronic copy of
this authorization by saving or printing from my own device.

 By checking this box and providing my signature below, I am indicating that 1) I am authorized
to sign, and 2) I consent to receive copy of this authorization by saving or printing from my
own device.

 I signed on behalf of Insured/Claimant as ________________ (Relationship). Attach copy of

document (Conservator, Guardian, Power of Attorney) granting authority to act on
Insured/Claimant’s behalf.

Printed Name: Signature: Date:

Scott Hazle {{Sig_es_:signer1:signature}} {{Dte_es_:signer1:date}}

Authorized Representative Printed Name: Authorized Representative Signature: Date:

1
Aflac means Continental American Insurance Company or American Family Life Assurance Company of NY,
or American Family Life Assurance Company of Columbus.

Page 2 of 2
Health Care Provider Certification
of Medical Leave
Employee’s Own Serious Health Condition

Administrative Office Toll Free: (800) 206-8826

PO Box 8307 Fax: (800) 206-9472
Columbus GA 31908-8307 Email: myPLADSleave@aflac.com

Important tips when completing this form

If you plan to request a leave under the Family and Medical Leave Act (FMLA), you will need to complete and
return this medical certification form. To start, just complete Section I, send it to your healthcare provider to
complete Section II and return to us. It is important that this is sent back to us at least 15 calendar days from when
we sent it to you. If you do not get the form to us on time, is incomplete and/or insufficient, then we may not be
able to approve your leave (29 U.S.C. §§ 2613, 2614(c)(3)).

Section I: For Completion by the Employee

Employee’s Name Date of Birth Case Number
Scott Hazle 00442177

Name of Employer Job Title

Columbia Sportswear Company

Section II: For Completion by the Health Care Provider

Your patient made a request to be absent from work because of their own illness or injury. For us to make a
decision on their case, we will need you to complete the information below. Some of the information you complete
is used to approve their job protection through FMLA. When completing this form, we ask:
 Your answers are to your best estimate based on your medical knowledge, experience and examination of
the patient.
 Be as specific as you can. Using terms like "as needed", "unknown" or "indeterminate" may not be enough
to approve FMLA.
 Limit your responses to the medical condition for which the employee is seeking leave.
 Do not include 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).
Please note that some state or local laws may not allow disclosure of private medical information about the
patient's serious health condition, such as providing the diagnosis and/or course of treatment.
Check the box(es) for the questions below, as applicable. For all box(es) checked, the amount of leave needed must
be provided.
□ Inpatient Care: The patient ( □ has been / □ is expected to be ) admitted for an overnight stay in a hospital,
hospice, or residential medical care facility on the following date(s): _______________________________
□ Incapacity plus Treatment: (e.g. outpatient surgery, strep throat)
 Due to the condition, the patient ( □ has been / □ is expected to be ) incapacitated for more than three
consecutive, full calendar days.
 The patient ( □ was / □ will be ) seen on the following date(s): ____________________________________________
 The condition ( □ has / □ has not ) also resulted in a course of continuing treatment under the supervision
of a health care provider (e.g. prescription medication (other than over the counter) or therapy requiring special equipment)
□ Pregnancy: The condition is pregnancy. List the expected delivery date: _______________________ (mm/dd/yyyy)
*Us (or Company) means Continental American Insurance Company or American Family Life Assurance Company of NY,
or American Family Life Assurance Company of Columbus.

Page 1 of 3
Health Care Provider Certification of Medical Leave
Employee’s Own Serious Health Condition

Employee’s Name Date of Birth Case Number

Scott Hazle 00442177

Section II: For Completion by the Health Care Provider (continued)

□ Chronic Conditions: (e.g. asthma, migraine headaches) Treatment visits are expected to be at least twice per year
□ Permanent or Long-Term Conditions: Due to the condition, incapacity is permanent or long term and requires
the continuing supervision of a health care provider (even if active treatment is not being provided).
□ Conditions requiring Multiple Treatments: (e.g. chemotherapy treatments, restorative surgery) Due to the condition, it is
medical necessary for the patient to receive multiple treatments.
□ None of the above: If none of the above condition(s) were checked, (i.e., inpatient care, pregnancy) no additional
information is needed. Please sign and date the form.

Date condition was 1st diagnosed: _________________________ Last office visit: _______________________________________
Date you 1st examined the patient for this condition: Next office visit: _______________________________________
________________________________
Provide your best estimate of how long the condition
lasted or will last: ______________________________________
Primary serious health condition diagnosis description (Optional):

If the employer does not provide a statement of the employee's essential functions or a job description, answer
these questions based upon the employee's own description of the essential job functions. An employee who must
be absent from work to receive medical treatment(s), such as scheduled medical visits, for a serious health
condition is considered to be not able to perform the essential job functions of the position during the absence for
treatment(s).

Due to the condition, the employee ( □ was not able/ □ Is not able/ □ will not be able) to perform one or more
of the essential job functions(s). Identify at least one essential job function the employee is not able to perform:

Relevant medical facts relating to the condition requiring this leave (these facts may include diagnosis, symptoms,
or any regimen of continuing treatment such as the use of specialized equipment):

Continuous leave
□ My patient has/will be incapacitated for a single continuous period of time due to his/her medical condition,
including time for treatment and recovery beginning _____/_____/______ and ending _____/_____/_____.

*Us (or Company) means Continental American Insurance Company or American Family Life Assurance Company of NY,
or American Family Life Assurance Company of Columbus.

Page 2 of 3
Health Care Provider Certification of Medical Leave
Employee’s Own Serious Health Condition

Employee’s Name Date of Birth Case Number

Scott Hazle 00442177

Section II: For Completion by the Health Care Provider (continued)

Reduced Work Schedule leave
□ My patient will need to work a reduced work schedule due to his/her medical condition and associated
treatment and recovery period beginning ____/____/_____ and ending ____/____/____.

□ a reduced work day: limited to _____ hours per day

□ a reduced work week: limited to _____ day(s) per week
Intermittent leave
□ My patient is expected to have periodic flare-ups where intermittent absence from work will be medically
necessary beginning ____/____/_____ and ending ____/____/____. Select one of the following options:

□ Weekly Flare-ups: (e.g. 1 x per week lasting 4 hours) □ Monthly Flare-ups: (e.g. 1 x every 3 months lasting 1-2 days)
Frequency: _____ time(s) per week Frequency: (select one) □ ____ time(s) per month
Duration: _____ hour(s) or ____ day(s) per episode □ ____ time(s) every ___ month(s)
Duration: _____ hour(s) or _____ day(s) per episode

□ My patient is expected to attend follow-up treatment appointments for his/her medical condition beginning
____/____/_____ and ending ____/____/____.

Weekly Appointments: (e.g. 1 x per week lasting 2 hrs) Monthly Appointments: (e.g. 1 x per months lasting 8 hrs)
Frequency: _____ time(s) per week Frequency: (select one) □ ____ time(s) per month
Duration: _____ hour(s) □ ____ time(s) every ____ month(s)
Duration: _____ hour(s)

Health Care Provider Information and Signature

Health Care Provider Name: Specialty/Board Certification: Tax ID:

Health Care Provider's Business address:

Telephone: Fax Number: Email Address:

Health Care Provider Signature: Date:

_____________________________________________________________________ ________________________________________

*Us (or Company) means Continental American Insurance Company or American Family Life Assurance Company of NY,
or American Family Life Assurance Company of Columbus.

Page 3 of 3
Administrative Office Toll Free: (800) 206-8826
PO Box 8307 Fax: (800) 206-9472
Columbus GA 31908-8307 Email: myPLADSleave@aflac.com

Scott Hazle

00442177

*Us (or Company) means Continental American Insurance Company or American Family Life Assurance Company of NY,
or American Family Life Assurance Company of Columbus.

Page 1 of 3
 Scott Hazle 00442177

*Us (or Company) means Continental American Insurance Company or American Family Life Assurance Company of NY,
or American Family Life Assurance Company of Columbus.

Page 2 of 3
Claim - Fraud Warnings and Other Notices
Please review the warning and/or notice for your state, if applicable.

Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime,
and subjects such person to criminal and civil penalties.

Oregon – Any person who knowingly and with INTENT TO DEFRAUD or solicit another to defraud an insurer: (1)
by submitting an application, or (2) by filing a claim containing a false statement as to any MATERIAL FACT, MAY
BE violating state law.

Page 3 of 3