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---
excerpt: none
---
{% include head.html %}
<body class="no-js layout-claims layout-claims-new">
<a class="a-skip-to-main" href="#main">Skip to main content</a>
{% include site-header.html %}
<main role="main" id="main">
<div class="wrapper">
<form action="#" id="claim" method="get">
<h1 class="page-title">File a claim</h1>
<section class="claim-section claim-section-intent">
<h1>Claim information</h1>
<fieldset class="fieldset fieldset-radio fieldset-claim-reason">
<legend>Which of the following best describes <strong>the reason for your claim?</strong> <span class="instructions">(select one)</span></legend>
<div class="field field-radio">
<label>
<input type="radio" name="claim_reason" value="bond-with-a-child">
<span class="label-text">I need to bond with a newborn or newly adopted child.</span>
</label>
</div>
<div class="field field-radio">
<label>
<input type="radio" name="claim_reason" value="self-care">
<span class="label-text">I need to care for someone with a temporary disability or illness.</span>
</label>
</div>
<div class="field field-radio">
<label>
<input type="radio" name="claim_reason" value="care-for-a-family-member">
<span class="label-text">I need to manage my own recently diagnosed medical condition.</span>
</label>
</div>
</fieldset>
<div class="field field-date">
<label>
<span class="label-text">On what date will your claim start?</span>
<input type="date" name="claim_start_date" value="">
</label>
</div> </section>
<section class="claim-section claim-section-claimant-information">
<h1>Person claiming benefits</h1>
<fieldset class="fieldset fieldset-name">
<legend>Name</legend>
<div class="field field-name-first">
<label>
<span class="label-text">First</span>
<input type="text" name="claimant_name_first" minlength="1" maxlength="255">
</label>
</div>
<div class="field field-name-middle">
<label>
<span class="label-text">Middle</span>
<input type="text" name="claimant_name_middle" maxlength="255">
</label>
</div>
<div class="field field-name-last">
<label>
<span class="label-text">Last</span>
<input type="text" name="claimant_name_last" minlength="1" maxlength="255">
</label>
</div>
</fieldset>
<fieldset class="fieldset fieldset-address">
<legend>Mailing address</legend>
<div class="field field-street">
<label>
<span class="label-text">Street address</span>
<input type="text" name="claimant_address_street">
</label>
</div>
<div class="field field-city-state-zip">
<div class="field field-city">
<label>
<span class="label-text">City</span>
<input type="text" name="claimant_address_city">
</label>
</div>
<div class="field field-state field-select">
<label for="parties-requesting-agency-mailing-address-state">
<span class="label-text">State</span>
<span class="label-select">
<select type="text" name="claimant_address_state">
<option></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</span>
</label>
</div>
<div class="field field-zip">
<label>
<span class="label-text">Postal code</span>
<input type="text" name="claimant_address_zip">
</label>
</div>
</div>
<div class="field field-select field-country">
<label>
<span class="label-text">Country</span>
<select name="claimant_address_country">
<option>United States</option>
<option>Others</option>
</select>
</label>
</div>
</fieldset>
<div class="field field-text field-social-security-number">
<label>
<span class="label-text">Social Security Number</span>
<input type="text" name="claimant_ssn" maxlength="11" pattern="(?!666|000|9\d{2})([0-9]{3})([\s-]?)(?!00)([0-9]{2})\2(?!0{4})([0-9]{4})">
</label>
</div>
<fieldset class="fieldset fieldset-radio">
<legend>Is any other person ready, willing, and able to provide care for the same period this person is claiming PFL benefits?</legend>
<div class="field field-radio">
<label for="">
<input type="radio" name="alternative_caretaker" value="yes">
<span class="label-text">Yes</span>
</label>
</div>
<div class="field field-radio">
<label for="">
<input type="radio" name="alternative_caretaker" value="no">
<span class="label-text">No</span>
</label>
</div>
</fieldset>
</section>
<section class="claim-section claim-section-employment-information">
<h1>Employment information</h1>
<p>Benefit eligibility is primarily determined by the claimant’s employment history. Please provide information about the claimant’s current employment.</p>
<fieldset class="fieldset fieldset-employer">
<legend>Employer</legend>
<div class="field field-name">
<label>
<span class="label-text">Name</span>
<input type="text" name="employer_name">
</label>
</div>
<fieldset class="fieldset fieldset-address">
<legend>Mailing address</legend>
<div class="field field-street">
<label>
<span class="label-text">Street address</span>
<input type="text" name="employer_address_street">
</label>
</div>
<div class="field field-city-state-zip">
<div class="field field-city">
<label>
<span class="label-text">City</span>
<input type="text" name="employer_address_city">
</label>
</div>
<div class="field field-state field-select">
<label for="employer_address_state">
<span class="label-text">State</span>
<span class="label-select">
<select type="text" name="employer_address_state">
<option></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</span>
</label>
</div>
<div class="field field-zip">
<label>
<span class="label-text">Postal code</span>
<input type="text" name="employer_address_zip">
</label>
</div>
</div>
</fieldset>
</fieldset>
<div class="field field-date">
<label>
<span class="label-text">On what date will you return work?</span>
<input type="date" name="benefits_end">
</label>
</div>
<fieldset class="fieldset fieldset-radio">
<legend>Do you plan on returning to work during your family leave period?</legend>
<div class="field field-radio">
<label for="">
<input type="radio" name="workers-comp" value="yes">
<span class="label-text">Yes</span>
</label>
</div>
<div class="field field-radio">
<label for="">
<input type="radio" name="workers-comp" value="no">
<span class="label-text">No</span>
</label>
</div>
</fieldset>
<fieldset class="fieldset fieldset-radio">
<legend>Have you claimed or do you plan to claim workers’ compensation benefits for any portion of the period covered by this claim?</legend>
<div class="field field-radio">
<label for="">
<input type="radio" name="workers-comp" value="yes">
<span class="label-text">Yes</span>
</label>
</div>
<div class="field field-radio">
<label for="">
<input type="radio" name="workers-comp" value="no">
<span class="label-text">No</span>
</label>
</div>
</fieldset>
<fieldset class="fieldset fieldset-radio">
<legend>May we disclose benefit payment information to your employer?</legend>
<div class="field field-radio">
<label for="">
<input type="radio" name="employer-disclosure" value="yes">
<span class="label-text">Yes</span>
</label>
</div>
<div class="field field-radio">
<label for="">
<input type="radio" name="employer-disclosure" value="no">
<span class="label-text">No</span>
</label>
</div>
</fieldset>
</section>
<section class="claim-section claim-section-dependent-information">
<h1>Dependent</h1>
<p>This information is only required for claimants who are either bonding with a child or caring for someone other than themselves.</p>
<fieldset class="fieldset fieldset-name">
<legend>Name</legend>
<div class="field field-name-first">
<label>
<span class="label-text">First</span>
<input type="text" name="claimant_name_first" minlength="1" maxlength="255">
</label>
</div>
<div class="field field-name-middle">
<label>
<span class="label-text">Middle</span>
<input type="text" name="claimant_name_middle" maxlength="255">
</label>
</div>
<div class="field field-name-last">
<label>
<span class="label-text">Last</span>
<input type="text" name="claimant_name_last" minlength="1" maxlength="255">
</label>
</div>
</fieldset>
<fieldset class="fieldset fieldset-address fieldset-residence">
<legend>Residence (if different from claimant)</legend>
<div class="field field-street">
<label>
<span class="label-text">Street address</span>
<input type="text" name="claimant_address_street">
</label>
</div>
<div class="field field-city-state-zip">
<div class="field field-city">
<label>
<span class="label-text">City</span>
<input type="text" name="claimant_address_city">
</label>
</div>
<div class="field field-state field-select">
<label for="parties-requesting-agency-mailing-address-state">
<span class="label-text">State</span>
<span class="label-select">
<select type="text" name="claimant_address_state">
<option></option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</span>
</label>
</div>
<div class="field field-zip">
<label>
<span class="label-text">Postal code</span>
<input type="text" name="claimant_address_zip">
</label>
</div>
</div>
<div class="field field-select field-country">
<label>
<span class="label-text">Country</span>
<select name="claimant_address_country">
<option>United States</option>
<option>Others</option>
</select>
</label>
</div>
</fieldset>
<div class="field field-select field-relationship">
<label>
<span class="label-text">Relationship</span>
<select name="claimant_relationship">
<option value="family">Family member (not child)</option>
<option value="friend">Friend </option>
<optgroup label="Child">
<option value="biological">Biological child</option>
<option value="step">Stepchild</option>
<option value="foster">Foster child</option>
<option value="adopted">Adopted child</option>
<option value="other">Other</option>
</optgroup>
</select>
</label>
</div>
</section>
<footer>
<button id="submit">Submit</button>
</footer>
</form>
<aside>
<h1>How does this work?</h1>
<ol class="steps">
<li>You’ll fill out and submit this form. We’ll provide a code to give to your healthcare provider.</li>
<li>You’ll notify your healthcare provider, who will provide information relevant to your claim. </li>
<li>We’ll process your application. You’ll receive an email when we receive the package, and once it’s been processed. (The average claims-processing time is currently 18 days.)</li>
<li>You’ll receive your benefits.</li>
</ol>
<p>If you have any questions, don't hesistate to <a href="#">contact us</a>. You can also <a href="#">read eligibility information</a>, <a href="#">estimate the benefits for which you qualify</a>, and <a href="#">request a paper form</a>.</p>
</aside>
</div>
</main>
{% include site-footer.html %}
</body>