November 2, 2017

New York Paid Family Leave: Model Forms Issued (article)

As mentioned in the August and September editions of the Benefit Beat, the New York paid family law takes effect January 1, 2018. The New York Workers’ Compensation Board recently issued model paid family leave request and certification forms, as well as a model employee opt-out or waiver form.


To receive paid family leave benefits, eligible employees will be required to complete and submit a Request for Paid Family Leave Form (Form PFL-1). Employees would complete Part A of Form PFL-1 indicating the covered reason and the length of leave. Employers complete Part B of Form PFL-1 and return it to the employee within 3 business days. It is the responsibility of the employee to submit Form PFL-1, together with any required supporting documentation to the paid family leave insurer.


In addition to the Form PFL-1, employees requesting paid family leave must complete and submit one of the additional forms listed below, depending on the reason for leave:

  • To bond with a newborn, adopted child, or foster child must complete and submit a Bonding Certification (Form PFL-2).
  • To care for a covered family member with a serious health condition must submit both a Release of Personal Health Information (Form PFL-3) and a Health Care Provider Certification (Form PFL-4).
  • To assist a family member with exigencies in connection with a military deployment must submit a Military Qualifying Event Certification (Form PFL-5).

For employees who are not expected to work a regular schedule of 20 or more hours per week for 26 consecutive weeks, or 175 days in a 52-consecutive week period, the employee can submit the employee opt-out or waiver form (PFL-Waiver). Employees who execute a waiver form would then be relieved from making payroll contributions to the cost of paid family leave benefits.  If the employee’s work schedule changes, such that the employee works 20 or more hours per week for 26 consecutive weeks, or works 175 days in a 52-consecutive week period, then the waiver would be revoked and the employee would then begin making payroll contributions to the cost of paid family leave benefits.


All of these forms are available on the dedicated Model Form webpage.  Additional information and program updates can be accessed on the Employer’s webpage

The information contained in this article is provided as general guidance and may be affected by changes in law or regulation. This article is not intended to replace or substitute for accounting or other professional advice. Please consult a CBIZ professional. This information is provided as-is with no warranties of any kind. CBIZ shall not be liable for any damages whatsoever in connection with its use and assumes no obligation to inform the reader of any changes in laws or other factors that could affect the information contained herein.  

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