Get C 4 2 Form

Filling out the C 4 2 Form for disability and paid family leave benefits can be straightforward with the right guidance. This guide provides clear, step-by-step instructions to help users complete the form accurately online.

Follow the steps to complete the C 4 2 Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin by filling out Section A, which requires the current employer information. This includes the employer's legal name, street address, city, state, ZIP code, Federal Employer Identification Number (FEIN), number of employees, and phone number.
3. Move to Section B to provide the plan information. Complete the fields for the WCB plan number, effective date of coverage, type of coverage (self-insurance or insurance carrier), name of the association, union, or trustees plan, and the insurance policy number if applicable.
4. In Section C, specify the coverage details. Indicate whether both disability and paid family leave benefits are provided, the class of employees covered, or if only paid family leave benefits are applicable.
5. If you are terminating a plan, complete Section D with the termination reason, including ‘non-payment of premium’ or ‘out of business,’ and the effective date of cancellation.
6. When applicable, complete Section E to provide reasons for modifying an existing plan if the supersedes box is checked.
7. Fill in Section F, where the association, union, or trustees must certify the information provided in the form is accurate. Include the date signed and full name and title of the official signing the form.
8. Complete Section G for the employer's initial certification. The employer must sign, provide their name, title, phone number, and the date of signing. A notary public must also certify the form.
9. Once all sections are completed, review the entire form for accuracy. You can then save your changes, download the completed form, print it, or share it electronically.

Complete your C 4 2 Form online today for an efficient application process.