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

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

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 insurance carrier.

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 insurance carrier.

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 insurance carrier.

Employee Paid Family Leave Opt-Out and Waiver of Benefits
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.

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

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