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 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)
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

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 File: Send the completed form to the address below and provide a copy to your employer. 

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.

 

Employer's Response to Paid Family Leave Discrimination/Retaliation Complaint (PFL-DC-130)
Employer's Response to Paid Family Leave Discrimination/Retaliation Complaint (PFL-DC-130)

Within 30 days of receiving a Notice of Paid Family Leave Discrimination/Retaliation Complaint (Form PFL-DC-129) from the Board, employers must complete and submit this form (PFL-DC-130) to the Board. 

Where to File: Send the completed form to:

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

Section 32 Waiver Agreement: Paid Family Leave Discrimination/Retaliation Claim (PFL-32-D)
Section 32 Waiver Agreement: Paid Family Leave Discrimination/Retaliation Claim (PFL-32-D)

Form PFL-32-D is submitted when an employee, employer, and any representatives mutually agree to specific terms in order to settle a discrimination claim. 

Where to File: Send the completed form to: 

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

Stipulation for Paid Family Leave Discrimination/Retaliation Claim (PFL-300.5-D)
Stipulation for Paid Family Leave Discrimination/Retaliation Claim (PFL-300.5-D)

To be used for stipulations to uncontested facts or proposed findings, pursuant to 12NYCRR 300.5.

Where to File: Send the completed form to the address below. 

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

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. 

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