Form Pfl-1 And Pfl-2 - Paid Family Leave Forms Page 7

ADVERTISEMENT

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 B - EMPLOYER INFORMATION (to be completed by the employer) - continued from prior page
Form PFL-1 continued from prior page
In the preceding 52 weeks has the employee taken leave for:
NYS Disability
PFL
Both Disability and PFL
None
11a.
11b. Enter the total number of weeks and days taken for both Disability and PFL in the last 52 weeks:
Please provide specific dates for Disability:
Weeks
Disability:
Days
Please provide specific dates for PFL:
Weeks
PFL:
Days
Yes
No
12. Is the employee taking Family Medical Leave Act (FMLA) concurrently with PFL?
13. PFL insurance carrier’s name and mailing address
PFL insurance carrier’s name
Mailing address
City, State
Zip code
Country (if not U.S.A.)
(
)
-
14. PFL insurance carrier’s telephone number
15. PFL policy number
Declaration and signature
I affirm the employee regularly works 20 or more hours per week and has been in employment for at least 26
consecutive weeks OR the employee regularly works less than 20 hours per week and has worked at least 175 days.
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 the person authorized to sign as the employer of the employee requesting PFL. My signature affirms that to the best of my knowledge and belief, the
information I have provided is true and accurate.
Employer’s authorized signature
Date signed (MM/DD/YYYY)
/
/
Title
PFL-1 (10-17)
If you need assistance, please call (844) 337-6303
Page 4 of 4

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 10