Fillable Applying For Paid Family Leave Bonding (Form PFL-1) (Daemen College)

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Applying For Paid Family Leave Bonding (Form PFL-1) (Daemen College)

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The Applying For Paid Family Leave Bonding (Form PFL-1) (Daemen College) form is 16 pages long and contains:

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Applying For Paid Family Leave – Bonding
(Form PFL-1)
Bond with a newborn, a newly adopted or fostered child
Complete Form PFL-1
• Complete PFL-1, Part A
• Provide PFL-1 to employer
• Employer completes PFL-1, Part B and returns to you within 3 days
Complete Form PFL-2
• Complete PFL-2 and collect supporting documentation
Send forms and documents
• Send completed forms and supporting documentation to insurance carrier
• Insurance carrier accepts or denies claim within 18 days
Please keep a copy of all pages for your records.
To Use Paid Family Leave To:
Applying For Paid Family Leave – Bonding
Page 1 of 1
If you need assistance, please call 800.535.2710
www.amtrustdb.com
DO NOT SCAN
Send completed form to:
Wesco Insurance Company
An AmTrust Financial Company
P.O. Box 980 at Bowling Green Station
New York, NY 10274
Email: dbclaims@amtrustgroup.com
or Fax: 800.584.9303
For inquiries:
Please call 800.535.2710
PART A - EMPLOYEE INFORMATION (to be completed by employee)
Paid Family Leave (PFL) Request (to be completed by the employee)
Employment Information (to be completed by the employee)
The employee requesting PFL must complete all required information.
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 specic 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 t 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.
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 sufcient.
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:
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).
Form PFL-1 Instructions continued on next page
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
Average Weekly Wage = $525
Prorated Weekly Bonus = $50
+________
Average Weekly Wage (including bonus) = $575
Request For Paid Family Leave – Bonding (Form PFL-1) Instructions
• To request PFL, the employee requesting PFL must complete Part A of the Request For Paid Family Leave (Form PFL1).
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 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.
Form PF1-1 Instructions
Page 1 of 2
If you need assistance, please call 800.535.2710
www.amtrustdb.com
DO NOT SCAN
PART A - EMPLOYEE INFORMATION (to be completed by employee)
FORM PFL-1 INSTRUCTIONS - CONTINUED FROM PRIOR PAGE
Form PFL-1 Instructions continued from prior page
If you are pre-submitting form: Indicate if the employee is pre-submitting their PFL request. Pre-submitting is dened 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 submitting. If pre-submitting is permitted by the carrier or self-insured employer, the missing information must be supplied as
soon as it is known. Benets 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 ve days which 1) states the claim is pending;
2) identies 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 within ve days to the employee with an explanation 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.
Questions 2: If a Social Security Number is used for the Federal
Employer Identication Number (FEIN), enter the Social Security
Number.
Questions 3: Enter the employer’s Standard Industrial
Classication (SIC) Code. Contact your carrier if you don’t know
your SIC code.
Question 8: The employee occupation code can be found at:
www.bls.gov/soc/2010/soc_alph.htm
Question 9: Enter the wages earned by the employe 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 on page 1 of the
instructions.) Calculate the gross average weekly wage by adding
up the gross amounts paid, and then divide 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.If the explanation will not t 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 last four digits of his or her Social
Security number (or TIN) at the top of the attachment.
Question 11a: ‘Disability’ refers to NYS statutory required
disability. If the answer is “none,” enter a “0” for total weeks and
days in Question 12b.
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.
Question 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.
PART B - EMPLOYER INFORMATION (to be completed by employer)
The employer of the employee requesting PFL must complete all information in Part B.
Afrmation 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.
Employee signs and dates, before giving this form to their employer to complete Part B.
Be sure to complete the appropriate additional PFL form(s)
based on the type of PFL leave being requested.
Notication Pursuant to the New York Personal Privacy Protection Law (Public Ofcers 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 tax identication 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 tax identication number to the Board is voluntary. The Board will protect the
condentiality of all personal information in its possession, disclosing it only in furtherance of its ofcial duties and in accordance with applicable
state and federal law.
Form PFL-1 Instructions
Page 2 of 2
If you need assistance, please call 800.535.2710
www.amtrustdb.com
PART A - EMPLOYEE INFORMATION (to be completed by employee)
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
Applying For Paid Family Leave – Bonding
(Form PFL-1)
INSTRUCTIONS INCLUDED WITH FORM
1. Employee’s legal name (rst name, middle initial, last name)
_______________________________________________________________________
2. 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 TIN
-
-
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
Male
Female
Not designated / Other
9. Employee’s preferred language
English
Español
Polski
Italiano
Kreyòl ayisyen
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 Pacic Islander
Other race
Form PFL-1 Instructions continued on next page
Form PFL-1 (10-17)
Page 1 of 4
If you need assistance, please call 800.535.2710
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PART A - EMPLOYEE INFORMATION (to be completed by employee) - continued from prior page
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name
(rst name, middle initial, last name) __________________________________________________________________
Employee’s date of birth (MM/DD/YYYY)
/
/
Employment Information (to be completed by the employee)
Declaration and signature
Any person who knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, or self-insurer, any information
containing any false material statement or conceals any material fact shall be guilty of a crime and subject to substantial fines and imprisonment.
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.
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
Form PFL-1 Instructions continued on next page
13. Will PFL be for a continuous period of time and/or periodic?
Continuous
PFL start date (MM/DD/YYYY) PFL end date (MM/DD/YYYY)
Dates are estimated
/
/
/
/
Periodic
Identify dates periodic PFL will be taken:
Dates are estimated
14. If providing less than 30 day’s advance notice to the employer, please explain:
___________________________________________________________________________________________________________________________________
15. Business name
_________________________________________________________________________________________________________________________________
16. Employee’s date of hire (MM/DD/YYYY)
/
/
17. Emplyee’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 Benets?
Yes No
Disclosure statement: Information regarding PFL benets received by the employee, such as payments received and types of leave, will be provided to the employer.
PFL-1 (10-17)
Page 2 of 4
If you need assistance, please call 800.535.2710
www.amtrustdb.com
PART B - EMPLOYER INFORMATION (to be completed by the employer)
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name
(rst name, middle initial, last name) __________________________________________________________________
Employee’s date of birth (MM/DD/YYYY)
/
/
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
If employee contribution is withheld, indicate taxable % (employer portion) for the FICA deductions = ___________ %
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 Classication (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/2010/soc_alph.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
1
2
3
4
5
6
7
8
Calculated average gross weekly wage:
9a. Is the employee Full-time or Part-time?
Full-time Part-time
9b. If Part-time, is employee on PFL waiver?
Yes No
10. If employee received or will receive full wages while on PFL, will employer be requesting reimbursement?
Yes No
PFL-1 (10-17)
Page 3 of 4
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PART B - EMPLOYEE INFORMATION (to be completed by employee) - continued from prior page
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name
(rst name, middle initial, last name) __________________________________________________________________
Employee’s date of birth (MM/DD/YYYY)
/
/
Declaration and signature
I afrm 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
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
Form PFL-1 Instructions continued on next 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
Please provide specic dates for Disability:
Days
Disability:
Weeks
Please provide specic dates for Disability:
Days
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 ________________________________________________________________________________________________________________________________
PFL-1 (10-17)
Page 4 of 4
If you need assistance, please call 800.535.2710
www.amtrustdb.com
Wesco Insurance Company
P.O. Box 980 at Bowling Green Station
New York, NY 10274
8 0 0
5 3 5
2 7 1 0
Bonding Certication (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 Certication (Form PFL-2) with the Request For Paid Family Leave (Form PFL-1).
Bonding Form/Certication Description
Health care provider certication of pregnancy
An original letter obtained from the birth mother’s health care provider that certies
pregnancy. It should include the mother’s name and the expected due date.
Health care provider certication of birth
An original letter obtained from the birth mother’s health care provider that includes
the mother’s name and child’s date of birth.
Birth Certicate A copy of the certicate issued by the city or county ofce in which the child is born.
Voluntary Acknowledgment of
Paternity (Form LDSS-4418)
A copy of the form that establishes legal fatherhood when the parents are unmarried.
Completed by both mother and father.
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 mother and
father. For more information, visit childsupport.ny.gov/dcse/aop_howto.html
Marriage Certicate
A copy of the ofcial statement issued by the town or city clerk from which the
marriage certicate was issued.
Civil union/domestic partner’s
documentation
A copy of the certicate 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 nalizing adoption or documentation in furtherance or
court order nalizing adoption.
Other documentation
Other documentation of parental relationship may be accepted if none of the others
listed apply.
BONDING CERTIFICATION (to be completed by 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
presubmitting. 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 nalized. 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 specied, do not send the original documents.
Form PFL-2 Instructions
Page 1 of 1
If you need assistance, please call 800.535.2710
www.amtrustdb.com
DO NOT SCAN
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 tax 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 tax 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.
Request For Paid Family Leave
Bonding Certication (Form PFL-2)
BONDING CERTIFICATION (to be completed by the employee)
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name) Employee’s date of birth (MM/DD/YYYY)
______________________________________________________________
/
/
Other last names, if any, under which employee has worked Employee’s Social Security Number or TIN
______________________________________________________________
-
-
Employee’s mailing address
Mailing address
City, State Zip code Country (if not U.S.A.)
1. Child’s date of birth (MM/DD/YYYY)
/
/
2. Child’s gender Male Female Not designated/Other
3. Does child live with the employee requesting PFL?
Yes No
4. Child is employee’s:
Biological child Stepchild Foster child Adopted child Legal ward Spouse/Domestic partner’s child
5. Select one of the following and attach the document as required as evidence of the relationship.
Parent of newborn child:
Birth mother:
Health care provider certication of pregnancy (include expected due date AND mother’s name); OR
Health care provider certication of birth (include date of birth of child AND mother’s name); OR
Child’s birth certicate
Other parent:
Copy of birth certicate naming second parent; OR
Voluntary acknowledgment of paternity; OR
Court order of liation; OR
Birth mother documents (see above) PLUS one of the following:
Marriage certicate; OR
Certicate of civil union; OR
Evidence of domestic partnership
OR; Other documentation of parental relationship
Foster parent:
Letter of foster care placement or anticipated placement issued by county or city department of Social Services or authorized voluntary foster care agency
Adoptive parent:
Court document nalizing adoption
Documentation in furtherance of adoption
6. Date of foster care or adoption placement, if applicable (MM/DD/YYYY)
/
/
PFL-2 (10-17) Bonding Certication
Page 1 of 2
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DO NOT SCAN
Form PFL-2 continued on next page
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name)
__________________________________________________________________________________________
Employee’s date of birth (MM/DD/YYYY)
/
/
FORM PFL-2 - CONTINUED FROM PRIOR PAGE
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)
BONDING CERTIFICATION (to be completed by the employee) - continued from prior page
Form PFL-2 continued from prior page
PFL-2 (10-17) Bonding Certication
Page 2 of 2
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MKT0341 11/17
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Applying For Paid Family Leave Bonding (Form PFL-1) (Daemen College)

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