Fillable Form 2.: Request for COVID-19 Quarantine PFL Child (Berkshire Hathaway GUARD Insurance Companies)

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Form 2.: Request for COVID-19 Quarantine PFL Child (Berkshire Hathaway GUARD Insurance Companies)

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  • 67 check-boxes
  • 125 other fields

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File type: PDF

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Request for COVID-19 Quarantine PFL – Child
(Form CCOVID19)
CCOVID19 (3-20)
Page 1 of 1
If you need assistance, please call (844) 337-6303
PaidFamilyLeave.ny.gov
SECTION 2 - MINOR CHILD INFORMATION (to be completed by the employee)
Instructions for taking Paid Family Leave for a Minor Dependent Child due to
COVID-19 Quarantine/Isolation
1. Complete Sections 1 – 3 of this form and Part A of the Request for Paid Family Leave (Form PFL-1).
a. Leave Questions 11 and 12 blank on Form PFL-1.
2.
Give completed forms to your employer.
a. Employer completes Section 4 of this form and Part B of Form PFL-1, within 3 business days.
3.
Attach mandatory or precautionary order of quarantine or isolation.
4. Submit all forms and order of quarantine/isolation to your employer’s PFL insurance carrier listed on Part B of Form PFL-1.
For further guidance, visit the PFL website at PaidFamilyLeave.ny.gov.
SECTION 1 - PAID FAMILY LEAVE (PFL) REQUEST (to be completed by the employee)
Reason for PFL request: Care for minor dependent child subject to COVID-19 Quarantine/Isolation
1. Minor dependent child’s name (rst name, middle initial, last name)
2. Minor child’s date of birth (MM/DD/YYYY)
3. Minor child’s mailing address
Street address
City State Zip Code Country (if not U.S.)
SECTION 3 - EMPLOYEE ATTESTATION (to be completed by the employee)
My signature afrms that I am not physically able to perform work for my employer through remote access or similar means
during my minor child’s mandatory or precautionary order of quarantine or isolation.
Employee Signature: ____________________________________________________________ Date: ___________________
Print Employee Name: __________________________________________________________
SECTION 4 - EMPLOYER ATTESTATION (to be completed by the employer)
My signature afrms that this employee is not physically able to perform their work through remote access or similar means
during their minor child’s mandatory or precautionary order of quarantine or isolation.
Employer Signature: ____________________________________________________________ Date: ___________________
Print Employer Name/Entity: ________________________________________________________________________________
The insurance carrier must pay or deny benets within 18 calendar days of receiving your completed request. Your request cannot be considered
incomplete solely because your employer failed to ll out Section 4 above or Part B of Form PFL-1.
If you disagree with the insurance carrier’s decision, or if payment is untimely, you may request arbitration with NAM (National Arbitration and
Mediation) at nyspa.com.
CCOVID19 3-20
click to sign
signature
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signature
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PART A - EMPLOYEE INFORMATION (to be completed by the employee)
Paid Family Leave (PFL) Request (to be completed by the employee)
Employment Information (to be completed by the employee)
Question 12: A child is dened as a biological, adopted,
or foster son or daughter, a stepson or stepdaughter, a
legal ward, a son or daughter of a domestic partner, or the
person to whom the employee stands in loco parentis. A
parent is dened 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.
Questions 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,
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:
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
The employee requesting PFL must complete all required information.
Form PFL-1 Instructions continued on next page
Request For Paid Family Leave (Form PFL-1) Instructions
To request 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 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 PFL-1 Instructions
Page 1 of 2
DO NOT SCAN
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
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.
•
•
•
•
Form PFL-1 Instructions
Page 2 of 2
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
PART B - EMPLOYER INFORMATION (to be completed by the employer)
Question 2: If a Social Security Number is used for the
Federal Employer Identication Number (FEIN), enter the
Social Security Number.
Question 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/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 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.
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.
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
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.
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).
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.
Request For Paid Family Leave
(Form PFL-1)
PFL-1 (11-17)
Page 1 of 4
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
PART A - EMPLOYEE INFORMATION (to be completed by the employee)
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 Русский Polski
中文 Italiano Kreyòl ayisyen 한국어
Other
- -
/ /
)( -
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
Paid Family Leave (PFL) Request (to be completed by the employee)
Form PFL-1 continued on next page
INSTRUCTIONS INCLUDED WITH FORM
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.)
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
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
Optional (for research purposes)
PFL-1 11-17
PFL-1 (11-17)
Page 2 of 4
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
Form PFL-1 continued from prior page
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 Benets? Yes No
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)
/ /
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.
)( -
/ /
PART A - EMPLOYEE INFORMATION (to be completed by the employee) - continued from prior page
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
14. If providing less than 30 day’s advance notice to the employer, please explain:
13. Will PFL be for a continuous period of time and/or periodic?
PFL start date (MM/DD/YYYY) PFL end date (MM/DD/YYYY)
Identify dates periodic PFL will be taken: Dates are estimated
/ / / /
Continuous
Periodic
Dates are estimated
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.
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name) Employee’s date of birth (MM/DD/YYYY)
/ /
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PFL-1 (11-17)
Page 3 of 4
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name)
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 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/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:
)( -
Form PFL-1 continued on next page
FORM PFL-1 - CONTINUED FROM PRIOR PAGE
10. If employee received or will receive full wages while on PFL, will employer be requesting reimbursement? Yes No
Employee’s date of birth (MM/DD/YYYY)
/ /
PFL-1 (11-17)
Page 4 of 4
If you need assistance, please call (844) 337-6303
www.ny.gov/PaidFamilyLeave
TO BE COMPLETED BY THE EMPLOYEE
Employee’s name (rst name, middle initial, last name)
Form PFL-1 continued from prior page
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 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 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 the person authorized to sign as the employer of the employee requesting PFL. My signature afrms 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
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:
Please provide specic dates for Disability:
Weeks
Days
PFL:
Please provide specic dates for PFL:
Weeks
Days
Employee’s date of birth (MM/DD/YYYY)
/ /
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Form 2.: Request for COVID-19 Quarantine PFL Child (Berkshire Hathaway GUARD Insurance Companies)

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Completed 9 January 2021

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