Form Pfl-1 And Pfl-2 - Paid Family Leave Forms
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10Applying For Paid Family Leave
To Use Paid Family Leave To:
Assist family members due to
Bond with a newborn, a newly
Care for a family member with a
another family member’s active
adopted or fostered child
serious health condition
military duty or impending
active duty abroad
Complete Form PFL-1
Complete Form PFL-1
Complete Form PFL-1
• Complete PFL-1, Part A
• Complete PFL-1, Part A
• Complete PFL-1, Part A
• Provide PFL-1 to employer
• Provide PFL-1 to employer
• Provide PFL-1 to employer
• Employer completes PFL-1,
• Employer completes PFL-1,
• Employer completes PFL-1,
Part B and returns to you
Part B and returns to you
Part B and returns to you
within 3 days
within 3 days
within 3 days
Complete Form PFL-2
Complete Form PFL-3
Complete Form PFL-5
• Complete PFL-2 and collect
• Care recipient completes
• Complete PFL-5 and collect
supporting documentation
PFL-3 and provides to health
supporting documentation
care provider
Send forms
Send forms
• Care recipient’s health care
and documents
provider keeps PFL-3
and documents
• Send completed forms and
• Send completed forms and
Complete Form PFL-4
supporting documentation to
supporting documentation to
insurance carrier
insurance carrier
• Complete “Employee”
information at the top of
• Insurance carrier accepts or
• Insurance carrier accepts or
PFL-4
denies claim within 18 days
denies claim within 18 days
• Provide PFL-4 to care
recipient’s health care
provider
• Care recipient’s health care
provider completes PFL-4
and returns to you
Send forms
and documents
• Send completed forms and
supporting documentation to
insurance carrier
• Insurance carrier accepts or
denies claim within 18 days
Please keep a copy of all pages for your records.
Applying For Paid Family Leave
If you need assistance, please call (844) 337-6303
DO NOT SCAN
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