Paid parental leave request form

When to complete the form

After you complete the form

  • You'll get email instructions for submitting proof of your child's birth or adoption
Employee information
First and Last
*
9 digits
*
xxx-xxx-xxxx
*
*
*
Leave request details
Reason for requesting leave

*
*
*
Has short-term disability claim been approved by the insurance carrier?

*
Signature

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

*
mm/dd/yyyy
*
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