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).
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 firstname.lastname@example.org to obtain a copy of this form.
Supplement to Certificate of Insurance (PFL-820.1)
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).