Fillable EMPLOYEES NOTICE TO Paid Family Leave is insurance (City University of New York)

Fill Online, Printable, Fillable, Blank EMPLOYEES NOTICE TO Paid Family Leave is insurance (City University of New York) Form

Use Fill to complete blank online CITY UNIVERSITY OF NEW YORK pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

EMPLOYEES NOTICE TO Paid Family Leave is insurance (City University of New York)

On average this form takes 2 minutes to complete

The EMPLOYEES NOTICE TO Paid Family Leave is insurance (City University of New York) form is 1 page long and contains:

  • 0 signatures
  • 2 check-boxes
  • 7 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City University of New York

BROWSE CITY UNIVERSITY OF NEW YORK FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
NOTICE TO
EMPLOYEES
Paid Family Leave Insurance
Coverage Provided by:
Covering Employees of:
INSERT INSURER NAME HERE
INSERT EMPLOYER NAME HERE
Paid Family Leave is insurance
that provides job protected
paid time o to:
• Bond with a newly born, adopted,
or fostered child
• Care for a family member with
a serious health condition
• Assist loved ones when a family
member is deployed abroad on
active military service
How to File:
• Notify your employer at least
30 days in advance, if foreseeable,
or as soon as possible
• Submit the Request for Paid Family
Leave form to your employer
• Complete and attach the additional
documentation as instructed on
the request form and submit to the
insurance carrier listed below
Employers should NEVER discriminate or retaliate against
anyone who requests or takes Paid Family Leave
You can get forms to take
Paid Family Leave from
• Your employer,
• The insurance carrier
below, or
• ny.gov/PaidFamilyLeave
FOR MORE INFORMATION AND HELP:
Visit ny.gov/PaidFamilyLeave
or call (844) 337-6303
INSERT NAME, ADDRESS, AND TELEPHONE NUMBER OF INSURER OR MAIN OFFICE OF AUTHORIZED NEW YORK SELF-INSURER
Policy #: Eective From: To:
☐ Statutory ☐ Under a Plan or Agreement
Class(es) of Employees Covered:
NOTICE OF COMPLIANCE
PRESCRIBED BY THE CHAIR, WORKERS’ COMPENSATION BOARD
THIS NOTICE MUST BE POSTED CONSPICUOUSLY IN AND ABOUT THE EMPLOYER’S PLACE OR PLACES OF BUSINESS.
PFL-120 (11-17)
Technology Insurance Company C/O AbSolve
New York
Technology Insurance Company
P.O. Box 1328
Mt. Laurel, NJ 08054
Phone: (800) 401-2691 Fax: (800) 728-7028
TDL10281277-001
01/06/2019
12/31/2020
All Eligible employees covered by the NYS Paid Family Leave Program per collectively bargained agreements with the City of New York and City of NY CUNY Jr Colleges
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

EMPLOYEES NOTICE TO Paid Family Leave is insurance (City University of New York)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document