Fillable Applying For Paid Family Leave Military (Form PFL-1) (City University of New York)

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Applying For Paid Family Leave Military (Form PFL-1) (City University of New York)

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Applying For Paid Family Leave – Military
(Form PFL-1)
Assist family members due to another family member’s
active military duty or impending active duty abroad
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-5
• Complete PFL-5 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 – Military
Page 1 of 1
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Send completed form to:
Technology Insurance Company
C/O AbSolve
P.O. Box 1328
Mt. Laurel, NJ 08054
Email: AmTrustNYDBLPFL@absencesolved.com
or Fax: 800.728.7028
For inquiries:
Please call 800.401.2691
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 – Military (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
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PART A - EMPLOYEE INFORMATION (to be completed by employee) - continued from prior page
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 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 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.
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.
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 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
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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 – Military
(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 continued on next page
Form PFL-1 (10-17)
Page 1 of 4
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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 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.
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
Form PFL-1 continued from prior 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
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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
PFL-1 (10-17)
Page 3 of 4
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Form PFL-1 continued on next 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)
/
/
7a. Employee’s last day worked (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
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
9c. Check usual days worked:
S M T W T F S
10. If employee received or will receive full wages while on PFL, will employer be
requesting reimbursement?
Yes No
PART B - EMPLOYER INFORMATION (to be completed by employer) - 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 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
Please provide specic dates for Disability:
Days
PFL:
Weeks
Please provide specic dates for PFL:
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
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Technology Insurance Company C/O AbSolve
P.O. Box 1328
Mt. Laurel, NJ 08054
8 0 0
4 0 1
2 6 9 1
Military Qualifying Event (Form PFL-5) Instructions
If an employee is requesting PFL because of a family member’s covered active military duty or impending covered active duty,
the employee must submit the Military Qualifying Event (Form PFL-5) with the Request For Paid Family Leave (Form PFL-1).
The employee must identify the family member, provide a copy of the member’s covered active duty orders or impending ac-
tive duty orders, and describe the reason leave is being requested.
MILITARY QUALIFYING EVENT (to be completed by employee)
The employee requesting PFL must complete all applicable requested information.
Employee enters their name, date of birth, other last names, if any, under which they have worked, Social Security or
Taxpayer Identication Number (TIN) number, and mailing address at the top of page 1.
Employee enters their name and date of birth at the top of page 2.
Questions 1 - 5: Enter the military member’s information, and indicate the military member’s relationship to the employee.
Question 6: Enter dates of expected military covered active duty.
Question 7: Documentation that shows that the military member is on covered active duty or has been notied of
an impending call or order to covered active duty is required and must be attached to this form. Select the type of
documentation that is attached from the list below.
Required documentation includes one of the following:
• Covered active duty orders; OR
• Letter from the military unit documenting impending call or order to covered duty; OR
• Documentation of military leave signed by the approving authority for military member’s Rest and Recuperation.
Form PFL-5 Instructions
Page 1 of 1
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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.
Qualifying Reason for Leave (to be completed by the employee)
Question 8: Explain the need for PFL because of the
Military Qualifying Event. For example: “My spouse was
just called on short notice to covered active duty status,
and will be deployed to (country) in ve days. I need to take
PFL to be with them and make arrangements for while they
are away on active duty.” 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, date of birth, other last names, if any,
under which they have worked, Social Security or Taxpayer
Identication Number (TIN) number, and mailing address at
the top of the attachment.
Question 9: Include one or more of the qualifying
supporting documents:
• Meeting announcement for informational brieng
sponsored by the military; or
• Document(s) conrming an appointment with a school
ofcial, doctor, attorney or nancial advisor; or
• Copy of a bill for services for the handling of legal or
nancial affairs.
Request For Paid Family Leave
Military Qualifying Event (Form PFL-5)
MILITARY QUALIFYING EVENT (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. Name of military member on covered active duty or impending call to covered active duty status (international deployment) (rst name, middle initial, last name)
_______________________________________________________________________________________________________________________________________________________
2. Military member’s date of birth (MM/DD/YYYY)
/
/
3. Military member’s gender Male Female Not designated/Other
4. Military member’s mailing address
Mailing address
City, State Zip code Country (if not U.S.A.)
5. The above-named military member is employee’s: Spouse Domestic partner Child Parent
6. Period of military member’s covered active duty(MM/DD/YYYY)
/
/
to
/
/
7. Please select one of the following and attach the indicated document to support that the military member is on covered active duty or impending call or order to
covered active duty status:
Covered active duty orders Letter of impending call or order to covered duty
Documentation of military leave signed by the approving authority for military member’s Rest and Recuperation
PFL-5 (10-17) Military Qualifying Event
Page 1 of 2
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Form PFL-5 continued on next page
Qualifying Reason for Leave (to be completed by the employee)
8. What is the reason employee is requesting PFL? (One or more reasons may be selected.)
Arranging for child care Acting as military member’s representative before a federal, state, or local agency for purpose
of obtaining, arranging, or appealing military service benets
Arranging for parental care Attending any event sponsored by the military or military service organizations
Counseling
Other
Making nancial arrangements
Making legal arrangements
INSTRUCTIONS INCLUDED WITH FORM
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-5 - 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)
MILITARY QUALIFYING EVENT (to be completed by the employee) - continued from prior page
Form PFL-5 continued from prior page
PFL-5 (10-17) Military Qualifying Event
Page 2 of 2
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9. Written documentation supporting this request for leave is available and attached?
Yes No None Available
Note: A complete and sufcient certication to support a request for PFL leave due to a qualifying event includes any available written documentation which supports the
need for leave; such documentation may include a copy of a meeting announcement for informational briengs sponsored by the military; a document conrming the military
member’s Rest and Recuperation leave; a document conrming an appointment with a third party, such as a counselor or school ofcial, or staff at a care facility; or a copy of
a bill for services for the handling of legal or nancial affairs. If leave is requested to meet with a third party, the employee must provide the supporting documentation of the
meeting that includes the name, address, appropriate contact information of the individual or entity with whom you are meeting (i.e., either telephone number, fax number, or
email address of the individual or entity).
QUALIFYING REASON FOR LEAVE - DOCUMENTATION
PFL-5-T (10-17) Template for Documentation
for Military Qualifying Event
If you need assistance, please call 800.401.2691
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MKT0708 11/18
If leave is requested to meet with a third party, the employee must provide supporting documentation of the meeting that includes the name, address, and appropriate contact information of the individual or entity
with whom you are meeting (i.e., either the telephone number, fax number or email address of the individual or entity). The reason for a meeting can include: arranging for child or parental care, counseling, making
nancial or legal arrangements, acting as the military member’s representative before a federal, state or local agency for purposes of obtaining, arranging or appealing military service benets, or attending any event
sponsored by the military or military service organizations.
Please submit this documentation for each required meeting/event.
Name of individual with whom employee is meeting ______________________________________________________________________________________________________
Title __________________________________________________________________________________________________________________________________________________
Organization __________________________________________________________________________________________________________________________________________
Telephone number (provide area or country code) ________________________________________________________________________________________________________________
Fax number (provide area or country code) ______________________________________________________________________________________________________________________
Email address _________________________________________________________________________________________________________________________________________
Mailing address ________________________________________________________________________________________________________________________________________
Mailing address
City, State Zip code Country (if not U.S.A.)
Describe nature of meeting. Include dates, if known:
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.)
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Applying For Paid Family Leave Military (Form PFL-1) (City University of New York)

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Completed 18 December 2020

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