NY Paid Family Leave (PFL)
Claim Forms & Process
To Get PFL Quote: Contact [email protected]
Paid Family Leave (PFL) - Claim Forms & Process
When an employee has a foreseeable situation, they should provide their employer 30 days advance notice of their intention to use Paid Family Leave. If the event was not foreseeable, the employee must notify their employer as soon as practical.
1) An employee should submit a completed claim package to their employer’s Paid Family Leave insurance carrier within 30 days of their
first day of paid leave. The insurance carrier must process the claim and issue a determination within 18 days.
2) A claim form will be available from an employer, the employer’s Paid Family Leave insurance carrier, or on the Paid Family Leave
website. Employers are also responsible for providing insurers with the dates that employees use Paid Family Leave.
| Bonding With Child | Forms to be Completed With Carrier | Certification Required In Addition to Claim Forms |
|
Birth Mother Filing
|
Form PFL 1: Request PFL Benefits • Part A: Employee To Complete
Employee To Complete |
The Birth Mother must submit: Note: The Document to include: Mother’s Name and Child’s Due Date or Birth Date |
|
Other Parent Filing
|
Form PFL 1: Request PFL Benefits • Part A: Employee To Complete
Employee To Complete |
The Second Parent must submit, if available; 1) A Birth Certificate Naming Them as a Parent, If this is Not Available, 2) The Second Parent May Submit; A Voluntary Acknowledgment of Paternity or A Court Order of Filiation Naming Them as a Parent If those Documents are Not Available, the Second Parent Can Submit: 1) Birth Documentation From the Birth Mother’s Health Care Provider and a) Either a Marriage Certificate or Evidence of a Civil Union or b) Domestic Partnership to Demonstrate the Relationship to the Birth Mother |
|
Foster Family Filing
|
Form PFL 1: Request PFL Benefits • Part A: Employee To Complete
Employee To Complete |
A Claim for Paid Family Leave to Bond with a Fostered Child Requires; 1) The Submission of a Letter of Placement Issued By a County or City Department of Social Services or Local Voluntary Agency. If a Second Parent is Not Named in Documentation; 1) A Copy of the Document Plus a Document Verifying the Relation to the Parent Named in the Foster Care Placement Will Be Needed |
|
Adoptive Parent Filing
|
Form PFL 1: Request PFL Benefits • Part A: Employee To Complete
Employee To Complete |
A Claim for Paid Family Leave to Bond with an Adopted Child Requires: 1) A Court Document Finalizing Adoption, or Paid Family Leave Taken before the Adoption is Complete, a Document Showing the Adoption Process is Underway. 2) Examples: Proof of a Pending Adoption Include: Statement From An Attorney, Adoption Agency or Adoption-Related Social Service Provider. If the Second Parent is Not Named in that Document; 1) They must also File Documentation Verifying the Relationship to the Parent Named in the Adoption. 2) If these Documents are not Available, the Second Parent May Submit other Documentary Evidence of Parental Relationship to Child, for Evaluation by Carrier. |
| Family Member Care | Forms to be Completed With Carrier | Certification Required In Addition to Claim Forms |
|
|
Form PFL 1: Request PFL Benefits Form PFL 3: Personal Health Info Form PFL 4: Health Care Provider Certification for Care of Family Members with Serious Health Condition. Health Care Provider Completes
|
FORM PFL 4: Must Be Fully Completed A Claim for Paid Family Leave to Care for a Family Member with a Serious Health Condition Requires: 1) A Medical Certification, Completed by the Care Recipient’s Health Care Provider. An Authorization for Personal Health Disclosure Form is Required by the HIPAA Privacy Rule; 1) And Must be Completed by the Care Recipient and Retained on File with the |
| Military Qualifying Event | Forms to be Completed and Filed With Carrier | Certification Required In Addition to Claim Forms |
|
Of Employee's Spouse, Domestic Partner, Child or Parent
|
Form PFL 1: Request PFL Benefits
Employee To Complete |
A Claim for Paid Family Leave to Assist Loved Ones when a Family Member is Deployed Abroad on Active Military Duty Generally requires; 1) Either a Form PFL-5 “Military Qualifying Event” Certification or a Those forms include: 2) Documentation of the Reason for Leave. |
