Paid parental leave request form

Before you fill out the form, the following must already have occurred:

  • You read about the paid parental leave program.
  • You submitted the leave of absence request form.
  • Your short-term disability claim is approved by The Standard unless you are not filing a short-term disability claim.
  • You have documentation verifying your child's date of birth or proof of petition for the adoption.

After submitting your request, you'll receive confirmation by email. If you don't receive the confirmation email, contact hr.lam.office@hennepin.us.

Employee information
First and Last
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9 digits
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xxx-xxx-xxxx
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Leave request details
Reason for requesting leave

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Has your short-term disability claim been approved by The Standard insurance carrier?



Send required documentation
Please send required documentation separately to hr.lam.office@hennepin.us.
Birth: Documentation verifying baby's date of birth. This document must include your name and your child's date of birth. You may submit the hospital birth record. The document does not need to be a certified birth certificate.
Adoption: Proof a petition for adoption has been filed with the court.
Note: Please block out your social security numbers and mailing address.
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Signature

By typing my name below, I am electronically signing this request form.

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mm/dd/yyyy
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