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Claim Form for Paid Family Leave
This template allows you to easily create a claim request form for paid family leave benefits. As you follow the form from top to bottom you are provided key questions to answer for the creation of your claim request. Answer questions thoroughly and provide complete documentation regarding the claim you are making.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes

Claim Form for Paid Family Leave TemplateForm 2311
Format: Word PDF
Category: Business, Payroll
Type: Form

Claim Form for Paid Family Leave

[SOCIAL SECURITY NUMBER]
[DATE OF BIRTH]
[PREFERRED LANGUAGE]

[NAME]

[ADDRESS]

[CITY, STATE ZIP CODE]

[PHONE NUMBER]

[EMAIL ADDRESS]

[EMPLOYER]

[ADDRESS]

[CITY, STATE ZIP CODE]

[PHONE NUMBER]

[EMAIL ADDRESS]

[DATE YOU LAST WORKED]
[PFL CLAIM TO START DATE]
[RETURN TO WORK DATE]

[YOUR OCCUPATION]
[WHY WILL YOU REDUCE YOUR WORK HOURS]

[NAME OF PERSON YOU ARE CARING FOR]

[IS ANY OTHER FAMILY MEMBER ABLE TO CARE FOR THE ABOVE LISTED FAMILY MEMBER?]

[HAVE YOU CLAIMED OR DO YOU PLAN TO CLAIM WORKERS’ COMPENSATION]

[IS THERE MORE THAN ONE EMPLOYEE?]

[WILL YOUR EMPLOYER CONTINUE TO PAY YOU WHILE YOU ARE ON FAMILY LEAVE?]

[MAY WE DISCLOSE YOUR BENEFIT PAYMENT INFORMATION TO YOUR CURRENT EMPLOYER?]

[WHILE ON FAMILY LEAVE WERE YOU IN THE CUSTODY OF LAW ENFORCEMENT AUTHORITIES?]

Signature: ___________________________________________________________________ Date: ___/___/_____