Paid Family Leave Forms

When you select a link to a form, you will be provided additional information, including when and where to file the form, and translated versions if available.

Paid Family Leave Request Forms

• Bond with a Newborn, a Newly Adopted or Fostered Child
• Care for a Family Member with Serious Health Condition
• Assist Families in Connection with a Military Deployment

Opt-Out/Waiver Form

• Employee Paid Family Leave Opt-Out and Waiver of Benefits (PFL Waiver)

Reinstatement and Discrimination Forms

• Formal Request for Reinstatement Regarding Paid Family Leave (PFL-DC-119)
• Paid Family Leave Discrimination/Retaliation Complaint (PFL-DC-120)

When you select a link to a form, you will be provided additional information, including when and where to file the form, and translated versions if available.

Applications for Voluntary Coverage (for Public Employers and Self-Employed Individuals)

• Employer’s Application for Voluntary Coverage (No Employee Contribution) (PFL-135)
• Employer’s Application for Voluntary Coverage (Employee Contribution Required) (PFL-136)

Employee Statement of Rights

• Statement of Rights for Paid Family Leave (PFL-271S)
• Statement of Rights for Paid Family Leave (PFL-271S) for 2019

Employee Opt-Out/Waiver Form

• Employee Paid Family Leave Opt-Out and Waiver of Benefits (PFL Waiver)

Discrimination / Retaliation Complaint Related

• Employer's Response to Paid Family Leave Discrimination/Retaliation Complaint (PFL-DC-130)
• Section 32 Waiver Agreement: Paid Family Leave Discrimination/Retaliation Claim (PFL-32-D)
• Stipulation for Paid Family Leave Discrimination/Retaliation Claim (PFL-300.5-D)

When you select a link to a form, you will be provided additional information, including when and where to file the form, and translated versions if available.

• Notice of Compliance
• Supplement to Certificate of Insurance (PFL-820.1)
• Statement of Rights for Paid Family Leave (PFL-271S)
• Statement of Rights for Paid Family Leave (PFL-271S) for 2019
• Paid Family Leave Request/Claim Denial Template (PFL-CR-001)

If you have difficulty in obtaining the Paid Family Leave forms or need help in completing these forms, please contact the PFL Helpline at (844)-337-6303.