Fillable Bonding Certification (Form PFL-2) Instruction

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Bonding Certification (Form PFL-2) Instruction

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Form PFL-2 Instructions
Page 1 of 1
LC-7729-2 (12/17)
Bonding Certification (Form PFL-2) Instruction
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
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 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 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.
Bonding Form/Certificatio 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.
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.
DO NOT SCAN
Request For Paid Family Leave
Bonding Certification (Form PFL-2)
INSTRUCTIONS INCLUDED WITH FORM
PFL-2 (11-17) Bonding Certification
Page 1 of 2
LC-7729-2 (12/17)
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
BONDING CERTIFICATION (to be completed by the employee)
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 Loco parentis
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)
/ /
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.)
Form PFL-2 continued on next page
PFL-2 11-17
Declaration and signature
Any person who knowingly and with intent to defraud any insurance company or other person les 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 ve thousand dollars and the stated value of the claim for each such violation.
I am hereby making a request for paid family leave benets under the NYS Workers’ Compensation Law. My signature afrms 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)
/ /
Form PFL-2 continued from prior page
BONDING CERTIFICATION (to be completed by the employee) - continued from prior page
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name)
FORM PFL-2 - CONTINUED FROM PRIOR PAGE
Employee’s date of birth (MM/DD/YYYY)
/ /
PFL-2 (11-17) Bonding Certification
Page 2 of 2
LC-7729-2 (12/17)
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
Fax or mail completed form to:
The Hartford
P.O.Box 14869
Lexington, KY 40512-4869
Fax Number: (833) 357-5153
Phone Number: (888) 301-5615
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Completed 15 December 2020

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