Form Pfl-1 And Pfl-2 - Paid Family Leave Forms (Page 2 of 10) in pdf

Request For Paid Family Leave (Form PFL-1) Instructions

•

To request PFL, the employee requesting PFL must complete Part A of the Request For Paid Family Leave (Form PFL-1).

All items on the form are required unless noted as optional. The employee then provides the form to the employer to

complete Part B.

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The employer completes Part B of the Request For Paid Family Leave (Form PFL-1) and returns it to the employee within

three days.

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Additional forms are required depending on the type of leave being requested. The employee requesting leave

is responsible for the completion of these forms.

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The employee submits the completed Request For Paid Family Leave (Form PFL-1) with the required additional

form to the employer’s PFL insurance carrier listed on Part B of Request For Paid Family Leave (Form PFL-1).

The employee should retain a copy of each submitted form for their records.

PART A - EMPLOYEE INFORMATION (to be completed by the employee)

The employee requesting PFL must complete all required information.

Paid Family Leave (PFL) Request (to be completed by the employee)

Questions 13:

If dates are “Continuous”, the employee

possible but in no event more than 18 days from the date of

must provide the start and end dates of the requested

the completed request.

PFL. These dates should be the actual dates that the PFL

Question 14:

If the employee is submitting the PFL

will begin and end. If uncertain, estimate the start and

request to their employer with less than 30 days’ advance

end dates and indicate “Dates are estimated”. If dates are

notice from the start date of the PFL, the employee must

“Periodic”, enter the dates PFL will be taken. Please be as

explain why 30 days’ notice could not be given. If the

specific as possible. If the dates are unknown or estimated,

explanation will not fit in the space provided on the form,

indicate “Dates are estimated”.

enter “See Attached” and add an attachment with the

If dates are estimated, the PFL carrier may require you to

explanation. Be sure to include the employee’s full name

submit a request for payment after the PFL day is taken.

and their date of birth at the top of the attachment.

Payment for approved claims will be due as soon as

Employment Information (to be completed by the employee)

Question 16:

Enter the date of hire to the best of the

Example of a gross weekly wage calculation:

employee’s recollection. If it has been more than a

Week 1 - Gross wage including overtime

$550

year since the date of hire, entering the year in which

Week 2 - Gross wage

$500

employment started is sufficient.

Week 3 - Gross wage

$500

Question 18:

Enter the best estimate of average gross

Week 4 - Gross wage

$500

weekly wage. Include only the wages earned from the

Week 5 - Gross wage

$500

employer listed on this request form. The gross weekly

Week 6 - Gross wage

$500

wage is the total weekly pay - including overtime, tips,

Week 7 - Gross wage, including overtime

$600

bonuses and commissions - before any deductions are

Week 8 - Gross wage, including overtime

$550

made by the employer, such as federal and state taxes.

Total =

$4,200

If the employer is not able to supply this information, the

Divide by 8

employee can calculate their gross weekly wage as follows:

Average Weekly Wage =

$525

Step 1: Add all gross wages received (before any

deductions) over the last eight weeks prior to the start of

Bonus earned in preceding 52 weeks

$2,600

PFL, including overtime and tips earned. (See Step 3 for

Divide by 52

instructions for calculating bonuses and/or commissions.)

Prorated Weekly Bonus =

$50

Step 2: Divide the gross wages calculated in step one by

Average Weekly Wage

$525

eight (or the number of weeks worked if less than eight)

Prorated Weekly Bonus

$50

to calculate the average weekly wage.

Average Weekly Wage (including bonus) =

$575

Step 3: If the employee received bonuses and/or

Please note that the employer is also required to provide

commissions during the 52 weeks preceding PFL, add

this information in Part B of the Request For Paid Family

the prorated weekly amount to the average weekly

Leave (Form PFL-1).

wage. To determine the prorated weekly amount, add all

bonuses/commissions earned in the preceding 52 weeks

Form PFL-1 Instructions continued on next page

and then divide by 52.

Form PFL-1 Instructions

If you need assistance, please call (844) 337-6303

DO NOT SCAN

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