New York Paid Family Leave (PFL) Model Form Documents

The New York Paid Family Leave (PFL) law requires employers to provide paid family leave benefits to eligible employees as part of the state’s disability insurance program. Starting January 1, 2018, New York employees will be eligible for PFL benefits. New York State has issued model documents related to the new law.

Below is a listing of the model documents and links to the form packets that must be completed in relation to the type of leave that is requested.

Form Documents
- Model Paid Family Leave Request (Form PFL-1). This document is to be completed by the eligible employee who is requesting time off. The employer must complete certain information on the form as well (Part B) and return the form to the employee within 3 days. The employee must submit the completed form and related documentation to the PFL carrier.

- In addition to the Leave Request and supporting documentation, the employee must also complete and submit a leave certification form, relevant to the type of leave:

  • Bonding Certification Form (Form PFL-2) to provide care to a newborn, adopted child or foster child
  • Release of Personal Health Information (Form PFL-3) and Health Care Provider Certification (Form PFL-4) to provide care to a family member with a serious health condition
  • Military Qualifying Event Certification (Form PFL-5) to address needs arising out of active military deployment

Links to Form Packets
The State has issued packets that include the necessary forms related to the type of leave request:

Bond with a Child, Care for Family Member with Health Condition and Assist Family Due to Active Deployment

Waiver Form
Employers must give eligible part-time employees the right to opt out of the program. If the employee chooses to opt out, they are to complete the following waiver form: Employee Opt-Out of Paid Family Leave Benefits Form (PFL Waiver)

Additionally, there are forms that can be completed by the employee should they want to complete a Formal Request for Reinstatement Regarding Paid Family Leave or a Discrimination/Retaliation Complaint with the Workers’ Compensation Board.

The information contained in this document is neither intended nor implied to be legal or regulatory advice or counsel. It is provided for general informational purposes only and represents a summary based on publicly available sources. We make no representations about and assume no responsibility for the accuracy or completeness of information contained in this document and such information is subject to change without notice.

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