How to Fill Out Paid Family Leave Form

The process of filing a claim for Paid Family Leave is simple and straightforward. When making a claim, you must complete several forms and give supporting documents. You may file a PFL claim to bond with a child, provide care to an ailing family member, or for military reasons. Here, we take a look at how to fill out a paid family leave form.

Request for Paid Family Leave Form PFL-1 Instructions

To ask for paid family leave, the employee needs to fill out Part A of the PFL-1 form. All items on the documents are needed unless they are labeled optional. After completing the required section, the employee should give the form to their employer to finish Part B.

After completing Part B of the Form PFL-1, the employer should return it to the applicant within three business days. The employee will then take the form and all additional documentation to the employer’s insurance carrier. It’s essential for the employee to retain a copy of every submitted document for personal records.

1.      Part A-Employee Details

Part A of the PFL-1 form has the following parts that need to be completed by the employee:

• Employee’s official names.
• Other last names the employee has worked with.
• Street address, city, state, zip code, and country (if not the U.S.).
• The Social Security Number or TIN of the employee.
• Date of birth.
• Primary phone number.
• Preferred email ID while on Paid Family Leave.
• Gender.
• Preferred Language.
• Ethnicity or race (optional).
• Reason for requesting for Paid Family Leave: bond with a child, care for a family member, or military qualifying event.
• The relationship between the employee and the family member: child, spouse, domestic partner, parents, parents-in-law, grandparents, or grandchildren.
• Will the Paid Family Leave be for a continuous duration and/or periodic?
• Explanation of the notice if being given less than 30 days in advance to the employer.
• The name of the business.
• Date of hire.
• Work location.
• Average gross weekly wage.
• Phone number to contact for the PFL request.
• Does the employee have two employers?
• If the employer has more than one employer, are they taking paid family leave from the other employer?
• Is the employee getting Workers’ Compensation Lost Wage Benefits at the current time?
• Signature and date of signing.
• Confirm you are submitting the form in advance by ticking on the checkbox.

2.  Part B-Employer Details

The employer is required to complete the following details on the Part B section of the PFL-1 form:

• The full legal name of the company and mailing address.
• Employer’s FEIN.
• Standard Industrial Classification Code.
• Contact name for inquiries related to Paid Family Leave.
• Contact phone number of employer.
• Email address of employer.
• Date of hire of the employee.
• Employee’s occupation.
• Details of the last eight weeks of the employee’s gross wages and average gross weekly wage.
• If the employee received or will get full wages on paid family leave, will the employer ask for reimbursement?
• Has the employee gone on leave for NYS Disability, PFL, or both over the past 52 weeks?
• State the number of weeks and days the employee has taken for Disability or paid family leave in the past 52 weeks.
• Is the employee taking FMLA together with PFL?
• PFL insurance provider’s name and address.
• PFL insurance provider’s phone number.
• PFL policy number.
• Employer’s declaration and signature.

For more information on how to fill out paid family leave form, don’t hesitate to contact Pierce Jewett, PLLC at: (757) 624-9323.

This website contains general information about legal matters. The information you obtain at this site is not, nor is it intended to be legal advice. You should consult an attorney for legal advice regarding your individual situation.