Paid Family Leave: Forms for Employees, Employers and Insurance Carriers

TOP Paid Family Leave: Forms for Employees, Employers and Insurance Carriers
Employee Paid Family Leave Opt-Out and Waiver of Benefits

If an employee does not expect to work long enough to qualify for Paid Family Leave (a seasonal worker, for example), the employee may opt out of Paid Family Leave by completing the Waiver of Benefits Form.

 

Where to File: With the employee’s employer.

Formal Request for Reinstatement Regarding Paid Family Leave (PFL-DC-119)
Formal Request for Reinstatement Regarding Paid Family Leave (PFL-DC-119)

Employee files a Formal Request for Reinstatement Regarding Paid Family Leave (PFL-DC-119) to formally request reinstatement to the same or comparable position from their employer.

Where to File: File the completed form with your employer and send a copy to:

Paid Family Leave
PO Box 9030
Endicott, NY 13761-9030

Employer
Employer

Employer’s Application for Voluntary Coverage (No Employee Contribution) (PFL-135)

Employers exempt from providing mandatory Paid Family Leave may provide voluntary Paid Family Leave by completing PFL-135 (if no employee contribution is required).

Where to File: Bureau of Compliance, 328 State Street, Schenectady, NY 12305

 

Employer’s Application for Voluntary Coverage (Employee Contribution Required) (PFL-136)
Employer’s Application for Voluntary Coverage (Employee Contribution Required) (PFL-136)

Employers exempt from providing mandatory Paid Family Leave may provide voluntary Paid Family Leave by completing PFL-136 (if they will be requiring an employee contribution).

Where to File: Bureau of Compliance, 328 State Street, Schenectady, NY 12305

 

Statement of Rights for Paid Family Leave (PFL-271S)
Statement of Rights for Paid Family Leave (PFL-271S)

Employers must provide the Employee Statement of Rights (form PFL-271s) to employees when they take Paid Family Leave or take time off from work for a Paid Family Leave qualifying event, but have not requested Paid Family Leave. Employers may also provide this form to all employees to educate them about Paid Family Leave.

Where to File: This form is not filed.

 

Insurance Carrier
Insurance Carrier

Notice of Compliance- Paid Family Leave (PFL-120)

Upon securing Paid Family Leave insurance or Board-approved self-insurance, employers must obtain PFL-120 from their insurance carrier or licensed agent and display the form in a conspicuous location, similar to what they do for Workers’ Compensation and Disability Insurance.

Please email certificates@wcb.ny.gov to obtain a copy of this form.

 

Supplement to Certificate of Insurance (PFL-820.1)

Carriers insuring employers for disability and paid family leave benefits through Plan Coverage, Enriched Coverage, or Class Coverage should file PFL-820.1 form with DB-820/829.

Form: PFL-820.1

Paid Family Leave Request/Claim Denial Template (PFL-CR-001)
Paid Family Leave Request/Claim Denial Template (PFL-CR-001)

Insurance Carriers must provide notice of a total or partial denial of a request/claim for Paid Family Leave Benefits to the requester using this denial template (PFL-CR-001).

Where to File: This form is not filed with the Board.

Assistance
Assistance
WYSIWYG

If you have difficulty in obtaining the Paid Family Leave forms or need help in completing these forms, please contact the PFL Helpline at (844)-337-6303. 

0