Employee PFL Form

EMPLOYEE PFL FORM

This Employee Paid Family Leave (PFL) Form is an internal request and certification form used to request job-protected paid family leave under the employer's policy and applicable law. Completion of this form begins the administrative review and benefits determination process. Submission of incomplete or false information may delay or result in denial of benefits and may subject the employee to disciplinary action.

Personal Information

Employee Name:

Position & Employment Details

Date of Hire:     Work Location:

PFL Request Details

Select reason for PFL (check all that apply):
Care for newborn or newly placed child   Bonding with new child   Care for family member with serious health condition   Qualifying military event or caregiver leave

Anticipated Leave Start Date:     Anticipated Leave End Date:

Is this leave continuous or intermittent?   Continuous    Intermittent

Family / Care Recipient Information

Relationship:     Date of Birth:

I hereby authorize the named medical provider to release to Human Resources and designated employer representatives any information necessary to process this Paid Family Leave request, including diagnosis, treatment dates, and prognosis. I understand medical information will be maintained separately from my personnel file in accordance with applicable confidentiality requirements.

Employment History (Most Recent)

Dates Employed:

Employment History (Prior)

Dates Employed:

Education

Professional References

Legal Disclosures & Acknowledgements

At-Will Employment: Nothing in this form or in the provision of Paid Family Leave should be construed to alter the at-will employment relationship, unless expressly stated in a separate written agreement signed by an authorized company representative. Either the employee or the employer may terminate employment at any time, with or without cause or notice, to the extent permitted by law.

Equal Opportunity: The employer is an equal opportunity employer. Requests for leave are evaluated and administered without regard to protected characteristics. Reasonable accommodations and leave will be considered consistent with applicable law and company policy.

Privacy and Use of Medical Information: Medical information obtained in connection with this request will be treated as confidential and maintained separately from personnel records. Such information will be disclosed only to those with a legitimate need to know for the administration of leave and benefits, or as required by law.

Authorization & Certifications

I certify that the information in this form is true and complete to the best of my knowledge. I understand that making a false statement or omission in connection with a Paid Family Leave request may result in denial of benefits, recovery of improperly paid benefits, and disciplinary action up to and including termination.

By checking the boxes below, I authorize the employer and its authorized representatives to:

Obtain and review medical certification from the provider named above for the purpose of verifying need for leave and duration.
Contact the medical provider to clarify or authenticate the medical certification if necessary.
Verify prior employment history as submitted on this form.
Conduct background checks if required by my position or as necessary to verify information provided.

I understand that approval of Paid Family Leave is subject to eligibility, attainment of any applicable waiting periods, compliance with notice and certification requirements, coordination with other leave entitlements (such as accrued paid leave or short-term disability), and employer policies. I agree to provide timely updates to Human Resources if circumstances change.

Penalty Acknowledgement

I acknowledge that I may be required to reimburse the company for benefits paid in error and that disciplinary action, up to termination, may result from materially false statements or omissions provided in connection with this request. I further understand that submission of this form does not guarantee approval.

Acknowledgment

By signing below I confirm that I have read and understand the statements on this form, that the information I have provided is true and complete, and that I consent to the authorizations checked above.

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