PFL Bonding Leave Forms - PFL-1 and PFL-2

HOW TO REQUEST PAID FAMILY LEAVE

to bond with a newly born, adopted, or fostered child

BEFORE YOU APPLY FOR PAID FAMILY LEAVE

■

Check the eligibility requirements. See next page or visit PaidFamilyLeave.ny.gov/eligibility.

■

Plan your leave. Leave can be taken all at once or intermittently, but must be taken in full-day increments.

■

Notify your employer at least 30 days in advance, if foreseeable, or as soon as possible.

COMPLETE YOUR FORMS AND ATTACH REQUIRED DOCUMENTATION

■

Complete the Request for Paid Family Leave (Form PFL-1).

Note: This form has sections that need to be completed by you and by your employer.



Fill out your section, make a copy, and give the form to your employer to fill out Part B.



Your employer is required to return Form PFL-1 to you within three business days. If there is a delay,

you do not have to wait to proceed. Send the Form PFL-1 that you have filled out, along with the rest

of your request package, directly to your employer's insurance carrier.

■

Complete the Bonding Certification (Form PFL-2).



Complete Form PFL-2 and attach the required documentation. (See next page for details.)

SUBMIT TO YOUR EMPLOYER’S INSURANCE CARRIER

■

You must submit your

completed request

package to your

employer’s insurance

carrier within 30 days

after the start of your

leave to avoid losing

benefits.

Keep a copy of all forms

and documentation for

your records.

Mail or fax your Form PFL-1 and Form PFL-2, and required documentation to

your employer’s insurance carrier.

To find out who your employer’s insurance carrier is, you can:

■

Look for the Paid Family Leave poster in your workplace.

■

Ask your employer.

■

Look it up using the employer coverage search application on wcb.ny.gov.

If you cannot find your employer’s insurance carrier, call the Paid Family Leave

(PFL) Helpline for assistance: (844) 337-6303

The PFL Helpline is available Monday

- Friday, 8:30 a.m. to 4:30 p.m

Please do NOT submit your request package to the NYS Workers’

Compensation Board.

It is YOUR responsibility to submit the forms to the insurance carrier. It is NOT your employer’s responsibility.

PAIDFAMILYLEAVE.NY.GOV 1

PFL-FormBond-Cover-v2 11-22

PAID FAMILY LEAVE TO BOND WITH A NEWLY BORN, ADOPTED, OR FOSTERED CHILD

Important to know



In most cases, the insurance carrier must pay or deny benefits within 18 days of receiving your completed request

or your first day of leave, whichever is later. Your request cannot be considered incomplete solely because your

employer did not fill out Part B of Form PFL-1 within three business days.



If the carrier denies or fails to timely pay your benefits, or you have any other claim-related dispute, you may

request to have the carrier’s actions reviewed. More information can be found at nyspfla.namadr.com.



Complaints about employer discrimination or retaliation are resolved by a Workers’ Compensation Board Law

Judge after a hearing. If you believe that your employer has discriminated or retaliated against you for taking

or requesting Paid Family Leave, visit PaidFamilyLeave.ny.gov/protections or contact (844) 337-6303.

Eligibility



Parents can take job-protected, paid time off to

bond with their new child within the first 12 months

of the child’s birth, adoption or foster placement.



Most employees who work for private

employers in New York State are covered under

Paid Family Leave.

■

Full-time employees: If you work a regular

schedule of 20 or more hours per week,

you are eligible after 26 consecutive

weeks of employment with your employer.

■

Part-time employees: If you work a regular

schedule of less than 20 hours per week,

you are eligible after working for your

employer for 175 days, which do not need

to be consecutive.



Non-represented public employees may be

covered if their employer has voluntarily opted in

to provide the benefit. Union-represented public

employees may be covered if the benefit has

been negotiated through collective bargaining.



Citizenship and/or immigration status is not a

factor in employee eligibility.



If you believe you are eligible, you can apply for

Paid Family Leave and the insurance carrier will

make a determination.



If you have questions about eligibility rules,

call the PFL Helpline at (844) 337-6303

(Monday - Friday, 8:30 a.m. to 4:30 p.m.).

Required documentation

The required documentation varies based on the type of

leave, as outlined below:

FOR THE BIRTH OF A CHILD

The birth parent will need the following documentation:

■

A copy of the child’s birth certificate, if available, or an

original copy of a health care provider certification of birth.

A non-birth parent will need the following documentation:

■

A copy of the child’s birth certificate, if available, naming

them as the second parent, a Voluntary Acknowledgement

of Parentage, or a Court Order of Filiation.

■

Same documentation as birth parent and a second

document verifying the relationship to the birth parent,

such as a marriage certificate, civil union, or domestic

partner document.

FOR ADOPTION

A copy of court documents finalizing the adoption.

Documentation in furtherance of adoption.

If the second parent is not named in the legal

documents, the second parent must also provide proof

verifying the relationship to the parent named in the

court documents, such as a marriage certificate, civil

union, or domestic partner document.

FOR FOSTER PLACEMENT

Foster care placement letter issued by the county or city

department of social services or authorized voluntary

foster care agency.

If the second parent is not named in the placement letter,

the second parent must also provide proof verifying the

relationship to the parent named in the placement letter,

such as a marriage certificate, civil union, or domestic

partner document.

Remember: It is YOUR responsibility to

submit the forms to the insurance carrier.

It is not your employer’s responsibility.

For more information, visit PaidFamilyLeave.ny.gov or call (844) 337-6303.

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

• To request Paid Family Leave (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.

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

three business days.

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

is responsible for the completion of these forms.

• 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.

PFL Request (to be completed by the employee)

Question 12: A child includes a biological, adopted,

or fostered child, a stepchild, a legal ward, a child of a

domestic partner, or the person to whom the employee

stands in loco parentis. A parent is defined as a biological,

foster, or adoptive parent, parent-in-law, a stepparent, a

legal guardian, or other person who stood in loco parentis

to the employee when the employee was a child.

Question 13: If dates are “Continuous,” the employee

must provide the start and end dates of the requested PFL.

These dates should be the actual dates that the PFL will

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

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

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

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

indicate “Dates are estimated.”

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

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

Payment for approved claims will be due as soon as

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

the completed request.

Question 14: If the employee is submitting the PFL

request to their employer with less than 30 days’ advance

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

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

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

enter “See attached” and add an attachment with the

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

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

Employment Information (to be completed by the employee)

Question 16: Enter the date of hire to the best of the

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

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

employment started is sufficient.

Question 18: Enter the best estimate of average gross

weekly wage. Include only the wages earned from the

employer listed on this request form. The gross weekly

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

bonuses and commissions — before any deductions are

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

the employer is not able to supply this information, the

employee can calculate their gross weekly wage as follows:

Step 1:

Add all gross wages received (before any

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

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

instructions for calculating bonuses and/or commissions.)

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

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

to calculate the average weekly wage.

Step 3: If the employee received bonuses and/or

commissions during the 52 weeks preceding PFL, add

the prorated weekly amount to the average weekly wage.

To determine the prorated weekly amount, add all

bonuses/commissions earned in the preceding 52 weeks

and then divide by 52.

Example of a gross weekly wage calculation:

Week 1 - Gross wage including overtime $550

Week 2 - Gross wage $500

Week 3 - Gross wage $500

Week 4 - Gross wage $500

Week 5 - Gross wage $500

Week 6 - Gross wage $500

Week 7 - Gross wage, including overtime $600

Week 8 - Gross wage, including overtime

+ $550

Total = $4,200

Divide by 8 ÷ 8

Average Weekly Wage = $525

Bonus earned in preceding 52 weeks $2,600

Divide by 52 ÷ 52

Prorated Weekly Bonus = $50

Form PFL-1 Instructions continued on next page

Form PFL-1 Instructions

Page 1 of 2

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

paidfamilyleave.ny.gov

DO NOT SCAN

FORM PFL-1 INSTRUCTIONS - CONTINUED FROM PRIOR PAGE

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

Form PFL-1 Instructions continued from prior page

Average Weekly Wage $525

Prorated Weekly Bonus + $50

Average Weekly Wage (including bonus) = $575

Please note that the employer is also required to provide

this information in Part B of the Request for Paid Family

Leave (Form PFL-1).

When pre-submitting form: Indicate if the employee is

pre-submitting their PFL request. Pre-submitting is defined

as submitting the application in advance of an upcoming

qualifying event, with certain required information missing

due to the information being unknown at the time of the

submission. If pre-submitting is permitted by the carrier

or self-insured employer, the missing information must

be supplied as soon as it is known. Benefits cannot be

determined until all of the required information is provided.

The PFL insurance carrier or self-insured employer will

provide the employee a notice within five days which 1)

states the claim is pending; 2) identifies what information is

missing; 3) instructs how to submit the missing information.

Once all information is supplied, the PFL insurance

carrier or self-insured employer has 18 days to pay or

deny the claim.

If the carrier or self-insured employer does not permit pre-

submitting, the carrier or self-insured employer must return

the Request for Paid Family Leave to the employee within

five days explaining that the claim should be re-submitted

when all information is available.

Employee signs and dates before giving this form to their employer to complete Part B.

PART B - EMPLOYER INFORMATION (to be completed by the employer)

The employer of the employee requesting PFL must complete all information in Part B.

Question 2: If a Social Security number is used for the

Federal Employer Identification Number (FEIN), enter the

Social Security number.

Question 3: Enter the employer’s Standard Industrial

Classification (SIC) Code. Employers should contact their

carrier if they don’t know their SIC code.

Question 8: The employee occupation code can be found

at: www.bls.gov/soc/2018/major_groups.htm

Question 9: Enter the wages earned by the employee

during the last eight weeks preceding the PFL start date.

The gross amount paid is the employee’s gross weekly

pay, including any overtime and tips earned for that

week, plus the weekly prorated amount of any bonus or

commission received during the preceding 52 weeks. (For

detailed steps, see Question 18 starting on page 1 of the

instructions.) Calculate the gross average weekly wage by

adding up the gross amounts paid, and then dividing the

total by eight (or number of weeks worked if less than eight).

Question 10: Failure to select “Yes” for requesting

reimbursement from the insurance carrier will result in a

waiver of the right to reimbursement.

Question 11a: ‘Disability’ refers to NYS statutory required

disability. If the answer is “none,” enter a “0” for total weeks

and days in Question 11b.

Question 11b: The maximum number of weeks available

for NYS statutory disability and PFL in any 52-week period

is 26 weeks. Specify the total number of weeks, as well as

the number of additional days if the leave includes a partial

week, taken for NYS statutory disability and PFL during the

preceding 52 weeks.

Questions 13, 14 & 15: Enter the Paid Family Leave or

Disability/PFL insurance carrier’s name, address and PFL

policy number. If this employer is self-insured, enter the

name and address of where the PFL request should be

submitted for processing.

Affirmation employee is eligible for PFL: An employee who regularly works 20 hours or more per week must have been

in employment for at least 26 consecutive weeks. An employee who regularly works less than 20 hours per week must have

worked 175 days.

Employer signs and dates, and then returns to the employee requesting PFL within three business days.

Be sure to complete the appropriate additional PFL form(s)

based on the type of leave being requested.

Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 USC 552a).

The Workers’ Compensation Board’s (Board’s) authority to request that employees provide personal information, including their Social Security number or Taxpayer

Identification Number, is derived from the Board’s administrative authority under Workers’ Compensation Law section 142. This information is collected to assist the

Board in investigating and administering claims in the most expedient manner possible and to help it maintain accurate records. Providing your Social Security number

or Taxpayer Identification Number to the Board is voluntary. The Board will protect the confidentiality of all personal information in its possession, disclosing it only in

furtherance of its official duties and in accordance with applicable state and federal law.

Form PFL-1 Instructions

Page 2 of 2

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

paidfamilyleave.ny.gov

Request for Paid Family Leave

(Form PFL-1)

INSTRUCTIONS INCLUDED WITH FORM

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

1. Employee’s legal name (first name, middle initial, last name)

Other last names, if any, under which employee has worked

3. Employee’s mailing address

Street address

City, State

Zip code Country (if not U.S.A.)

4. Employee’s Social Security number or Taxpayer Identification Number

- -

5. Employee’s date of birth (MM/DD/YYYY)

/ /

6. Employee’s primary telephone number

( ) -

7. Employee’s preferred email address while on PFL (if available)

8. Employee’s gender

M F X

9. Employee’s preferred language

English Español Русский Polski

中文

Italiano Kreyòl ayisyen

한국어

Other

Optional (for research purposes)

10.

Employee’s ethnicity/race

For purposes of health demographic only. (U.S. Centers for

Disease Control and Prevention (CDC) code set, version 1.0.)

Is employee of Hispanic, Latino/a, or Spanish origin?

(One or more categories may be selected.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Dominican

Cuban

Another Hispanic, Latino/a, or Spanish origin

Not of Hispanic, Latino/a, or Spanish origin

Unknown

What is employee’s race?

(One or more categories may be selected.)

American Indian or Alaska Native

Black or African American

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

White

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Other race

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

11. Reason for PFL request:

Bond with child Care for family member Military qualifying event

12. The family member is employee’s:

Child Spouse Domestic partner Parent Parent-in-law Grandparent Grandchild

Sibling

Form PFL-1 continued on next page

PFL-1 (12-22)

Page 1 of 4

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

paidfamilyleave.ny.gov

PFL-1 12-22

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 intermittent?

Continuous

PFL start date (MM/DD/YYYY)

/ /

PFL end date (MM/DD/YYYY)

/ /

Dates are estimated

Intermittent

Identify dates intermittent PFL will be taken: Dates are estimated

14. If providing less than 30 days’ 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

( ) -

20a. Does employee have more than one employer?

Yes No

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

Yes No

21. Is employee currently receiving workers’ compensation lost wage benefits?

Yes No

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 (12-22)

Page 2 of 4

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

paidfamilyleave.ny.gov

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)

1. Business’s full legal name and mailing address

Business name

Mailing address

City, State Zip code Country (if not U.S.A.)

2. Employer’s FEIN

3. Employer’s Standard Industrial Classification (SIC) Code

4. Employer’s contact name for questions related to PFL

5. Employer’s contact telephone number

( ) -

6. Employer’s contact email address

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

/ /

8. Employee’s occupation Codes are available at:

www.bls.gov/soc/2018/major_groups.htm

9. Enter the last 8 weeks of gross wages for the employee and calculate the average gross weekly wage

Week no. Week ending date (MM/DD/YYYY) Number of days worked Gross amount paid

Calculated average gross weekly wage:

10.

If employee received or will receive full wages while on PFL, will employer be requesting reimbursement?

Yes No

Form PFL-1 continued on next page

PFL-1 (12-22)

Page 3 of 4

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

paidfamilyleave.ny.gov

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

11a.

In the preceding 52 weeks has the employee taken leave for:

NYS Disability PFL Both Disability and PFL None

11b. Enter the total number of weeks and days taken for both Disability and PFL in the last 52 weeks:

Disability:

Weeks

Days

Please provide specific dates for Disability:

PFL:

Weeks

Days

Please provide specific dates for PFL:

12. Is the employee taking Family Medical Leave Act (FMLA) concurrently with PFL?

Yes No

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 (12-22)

Page 4 of 4

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

paidfamilyleave.ny.gov

Bonding Certification (Form PFL-2) Instructions

If the employee is requesting PFL to bond with a newborn, an adopted child, or a foster child, the employee must

submit the Bonding Certification (Form PFL-2) with the Request for Paid Family Leave (Form PFL-1).

BONDING CERTIFICATION (to be completed by the employee)

The employee requesting PFL must complete all applicable requested information.

Send completed forms and supporting documentation to insurance carrier.

If this form is being submitted in advance (pre-submitting) and some information is unknown,

the insurance carrier will contact the employee and explain how to provide the required additional information.

Questions 1 & 2: If the form is submitted to the PFL insurance carrier prior to the birth of a child, this is considered pre-

submitting. The employee is then required to provide the required documentation of the child’s birth to the PFL insurance

carrier. The PFL carrier will tell the employee how to provide the required additional documentation.

There may be instances where PFL can be taken before the adoption or foster care is finalized. For example, the employee

may be required to appear in court or travel to another country as part of the adoption or foster care process. The employee

should include documentation to show that the PFL is necessary to further the adoption or foster care.

Question 5: See chart below for documentation details. Unless specified, do not send the original documents.

Bonding Form/Certification Description

Health care provider

certification of pregnancy

An original letter obtained from the birth parent’s health care provider that certifies

pregnancy. It should include the parent’s name and the expected due date.

Health care provider

certification of birth

An original letter obtained from the birth parent’s health care provider that includes the

parent’s name and child’s date of birth.

Birth Certificate

A copy of the certificate issued by the city or county office in which the child is born.

Voluntary Acknowledgment of

Parentage (Form LDSS-5171)

A copy of the form that establishes legal parentage when the parents are unmarried.

Completed by both parents.

For more information, see childsupport.ny.gov/dcse/aop_howto.html

Court Order of Filiation

A copy of the order from the family court that names the father of a child. Establishes legal

fatherhood when the parents are unmarried. Completed by both parents.

For more information, visit childsupport.ny.gov/dcse/aop_howto.html

Marriage Certificate

A copy of the official statement issued by the town or city clerk from which the marriage

certificate was issued.

Civil union/domestic partner’s

documentation

A copy of the certificate of civil union or domestic partnership.

Foster care placement letter

A copy of the letter of foster care placement issued by the county or city department of

social services or authorized voluntary foster care agency.

Court documents of adoption

A copy of the court document finalizing adoption or documentation in furtherance or court

order finalizing adoption.