Download An Application For Family Leave Insurance Benefits
This claim form for Family Leave Insurance benefits, form FL1, has been made available in PDF format for download (Adobe Acrobat Reader is required).
Pleaes note the application is in four (4) parts and includes an intermittent leave calendar.
1. Part A is to be completed by the Care Provider
2. Part B is to be completed by the Bonding Provider to bond with a newborn or newly adopted child
3. Part C is to be completed by both the Care Recipient and the Care Recipient's physician
NOTE: Only complete Part B or Part C, depending on the type of leave taken.
4. Part D is to be completed by the Employer.
The Intermittent Leave Schedule is to be completed only if you are taking intermittent leave. The schedule must be signed by the employer.
When completing the application make sure you put your name and social security number on each page of the application.
Mail or fax the complete application together. Separating portions of the application and sending separately will delay processing of your claim.
Read and follow all instructions included with the application.
Application Form (FL-1)
Pleaes note the application is in four (4) parts and includes an intermittent leave calendar.
1. Part A is to be completed by the Care Provider
2. Part B is to be completed by the Bonding Provider to bond with a newborn or newly adopted child
3. Part C is to be completed by both the Care Recipient and the Care Recipient's physician
NOTE: Only complete Part B or Part C, depending on the type of leave taken.
4. Part D is to be completed by the Employer.
The Intermittent Leave Schedule is to be completed only if you are taking intermittent leave. The schedule must be signed by the employer.
When completing the application make sure you put your name and social security number on each page of the application.
Mail or fax the complete application together. Separating portions of the application and sending separately will delay processing of your claim.
Read and follow all instructions included with the application.
Application Form (FL-1)
