Paid Family Leave: Forms for Employees

TOP Paid Family Leave: Forms for Employees
Overview
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The following Paid Family Leave forms for employees are now available:

 

Paid Family Leave Request Forms

Bond with a Newborn, a Newly Adopted or Fostered Child
Care for a Family Member with Serious Health Condition
Assist Families in Connection with a Military Deployment

Opt-Out/Waiver Form

Employee Paid Family Leave Opt-Out and Waiver of Benefits (PFL Waiver

Reinstatement and Discrimination Forms

Formal Request for Reinstatement Regarding Paid Family Leave (PFL-DC-119)
Paid Family Leave Discrimination/Retaliation Complaint (PFL-DC-120)

 



 

NOTE: Paid Family Leave forms are also available in other preferred languages (see below). 

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Employee Forms
Employee Forms

Bond with a Newborn, a Newly Adopted or Fostered Child

Employee is requesting Paid Family Leave to take time off to bond with a newly born, adopted, or fostered child.

Where to File: Send completed forms and supporting documentation to your employer’s Paid Family Leave insurance carrier at the address provided in the PFL-1 Form Part B, Question 13 (the section your employer completed), or directly to your employer if they are self-insured. If the information is not on the form:

  • ask your employer for the carrier’s address, or
  • contact the Paid Family Leave Helpline at 844-337-6303 for assistance.

Care for a Family Member with Serious Health Condition
Care for a Family Member with Serious Health Condition

Employee is requesting Paid Family Leave to take time off to care for a family member with a serious health condition.

Where to File: Send completed forms and supporting documentation to your employer’s Paid Family Leave insurance carrier at the address provided in the PFL-1 Form Part B, Question 13 (the section your employer completed), or directly to your employer if they are self-insured. If the information is not on the form:

  • ask your employer for the carrier’s address, or
  • contact the Paid Family Leave Helpline at 844-337-6303 for assistance.

Assist Families in Connection with a Military Deployment
Assist Families in Connection with a Military Deployment

Employee is requesting Paid Family Leave to help relieve family pressures when someone is called to active military service abroad.

Where to File: Send completed forms and supporting documentation to your employer’s Paid Family Leave insurance carrier at the address provided in the PFL-1 Form Part B, Question 13 (the section your employer completed), or directly to your employer if they are self-insured. If the information is not on the form:

  • ask your employer for the carrier’s address, or
  • contact the Paid Family Leave Helpline at 844-337-6303 for assistance.

Employee Paid Family Leave Opt-Out and Waiver of Benefits
Formal Request for Reinstatement Regarding Paid Family Leave (PFL-DC-119)
Paid Family Leave Discrimination/Retaliation Complaint (PFL-DC-120)
Paid Family Leave Discrimination/Retaliation Complaint (PFL-DC-120)

An employee files PFL-DC-120 when their employer has not replied within 30 days or they were not satisfied with their employer’s response to their Formal Request for Reinstatement Regarding Paid Family Leave(PFL-DC-119). 

Where to FileSend the completed form to the address below and provide a copy to your employer. 

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

Additional Forms
Additional Forms
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Assistance
Assistance
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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. 

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