Paid Family Leave: Forms for Insurance Carriers

TOP Paid Family Leave: Forms for Insurance Carriers
Overview
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The following Paid Family Leave forms for insurance carriers are now available:

 

Notice of Compliance - PFL 120
Supplement to Certificate of Insurance (PFL-820.1)
Statement of Rights for Paid Family Leave (PFL-271S)
Paid Family Leave Request/Claim Denial Template (PFL-CR-001)

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

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Insurance Carrier Forms
Insurance Carrier Forms
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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

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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.

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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