Form Pfl-1 And Pfl-2 - Paid Family Leave Forms (Page 5 of 10) in pdf

Form Pfl-1 And Pfl-2 - Paid Family Leave Forms Page 5

FORM PFL-1 - CONTINUED FROM PRIOR PAGE

TO BE COMPLETED BY THE EMPLOYEE

Employee’s name (first name, middle initial, last name)

Employee’s date of birth (MM/DD/YYYY)

PART A - EMPLOYEE INFORMATION (to be completed by the employee) - continued from prior page

Form PFL-1 continued from prior page

13. Will PFL be for a continuous period of time and/or periodic?

PFL start date (MM/DD/YYYY)

PFL end date (MM/DD/YYYY)

Continuous

Dates are estimated

Identify dates periodic PFL will be taken:

Dates are estimated

Periodic

14. If providing less than 30 day’s advance notice to the employer, please explain:

Employment Information (to be completed by the employee)

15. Business name

16. Employee’s date of hire (MM/DD/YYYY)

17. Employee’s work location

Street address

City, State

Zip code

Country (if not U.S.A.)

18. Employee’s average gross weekly wage (This data will be requested of both employee and employer)

(

)

19. Employer’s telephone number for contact regarding this request

Yes

20a. Does employee have more than one employer?

Yes

20b. If yes, is employee taking PFL from the other employer?

Yes

21. Is employee currently receiving Workers’ Compensation Lost Wage Benefits?

Disclosure statement: Information regarding PFL benefits received by the employee, such as payments received and types of leave, will be provided to the employer.

Declaration and signature

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing

any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,

which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

I am hereby making a request for paid family leave benefits under the NYS Workers’ Compensation Law. My signature affirms that the information I am

providing is true and accurate to the best of my knowledge and belief.

Employee’s signature

Date signed (MM/DD/YYYY)

I am submitting this form in advance (see instructions about pre-submitting). I understand the insurance carrier will contact me to advise how to submit the

required missing information.

PFL-1 (10-17)

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

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