Employee PFML Notice

EMPLOYEE PFML NOTICE

Purpose: This notice documents an employee's request for Paid Family and Medical Leave (PFML) and confirms the employee's receipt of the employer's PFML rights and obligations. Complete all applicable fields and sign to certify the accuracy of provided information. Submission constitutes authorization to the employer and its administrator to process the claim and to request or review supporting documentation.

Personal Information

Position Information

PFML Leave Request Details

Leave type (select all that apply): Family care of a covered individual Own serious health condition Bonding with a newborn or newly placed child

Substitution of accrued paid leave: I elect to substitute accrued paid leave during PFML

Notice of Rights, Protections and Employer Obligations

Eligibility and benefit levels are determined under applicable PFML statutes and the employer's PFML plan. Eligible employees may receive wage replacement subject to statutory caps, verification requirements, and any applicable waiting periods.

Job protection: Subject to applicable law, an eligible employee taking PFML will be reinstated to the same or an equivalent position upon return, except where a lawful exception applies (for example, a bona fide layoff that would have occurred regardless of the leave). An employee designated as a “key employee” under law may have limited reinstatement rights as determined by statute and the employer.

Health benefits: The employer will maintain group health plan coverage for an employee on PFML under the same terms as if actively working, provided the employee continues to make required employee contributions. Failure to maintain required premium payments may result in loss of coverage as permitted by law.

Certification and documentation: The employer or its administrator may require medical certification, documentation of family relationship, birth/adoption records, or other supporting documentation to determine eligibility. The employee must provide timely certification and reasonable documentation. Failure to provide required documentation may delay or deny benefits.

Prohibition on interference and retaliation: The employer will not interfere with an employee’s exercise of PFML rights nor retaliate against an employee for requesting or taking PFML. Any adverse action that is motivated by PFML activity may be unlawful and subject to administrative or legal remedies.

Fraud and penalties: Knowingly providing false statements or fraudulent documentation to obtain PFML is prohibited and may result in disciplinary action, recovery of paid benefits, denial of future benefits, and civil or criminal penalties under applicable law.

Employer Contact for PFML Administration

Required Documentation (check all provided)

Birth/adoption placement records Medical certification from a health care provider Other supporting documentation

Employment History (for verification)

Employer 1

Employer 2

Education

References

Reference 1

Reference 2

Reference 3

Legal Disclosures

At-Will Employment: Unless expressly provided otherwise in a written employment agreement signed by an authorized representative of the employer, employment is at will and may be terminated by either the employee or the employer at any time, with or without cause or notice, subject to statutory protections such as PFML.

Equal Opportunity: The employer is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, veteran status, or other protected characteristics. PFML requests will be considered without discriminatory treatment.

Authorization and Applicant Certification

By signing below, I certify under penalty of perjury that the information provided on this form is true, accurate, and complete to the best of my knowledge. I authorize the employer and its authorized agents or administrators to obtain and verify employment history, medical records and other information necessary to evaluate this PFML request. I consent to the release of medical information to the extent necessary for claim adjudication and benefit payment.

I acknowledge that failure to provide accurate information or to timely submit required documentation may result in delay, denial, or recovery of benefits and may subject me to disciplinary action up to and including termination. I understand my rights to job protection, continuation of benefits, and the employer's obligations as stated above, and I acknowledge receipt of this PFML Notice.

I acknowledge receipt of the PFML Notice and the information contained herein

I authorize the employer to contact prior employers and healthcare providers as necessary to verify information related to this request

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