Paid parental leave request form

When to complete the form

After you complete the form

For submitting proof of your child's birth or adoption to complete your request, you must follow the instructions that will be emailed to you.

The document must include the employee's name and the child's date of birth. You may submit the hospital birth record. The document does not need to be a certified birth certificate. 

For adoption, show proof that a petition of adoption has been filed with the court.

Please block out your social security numbers and mailing address.

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

*
Please check one of the following:

*
If you are the birth parent, has a 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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