This form is an application for Family and Medical Leave. It is to be filled out by an employee who is requesting a leave of absence.
Fmla Application Forms For Family Member
State:
Multi-State
Control #:
US-AHI-200
Format:
Word
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FAQ
1. Obtain a Paper Claim FormVisit Online Forms and Publications and order a form online. A form will be mailed to you.Obtain the form from your physician/practitioner or employer.Visit an SDI Office.Call 1-877-238-4373. California Relay Service (711) Provide the PFL number (1-877-238-4373)
Benefits Provided Paid family and medical leave provides Massachusetts employees with up to 12 weeks of job-protected, paid family leave, up to 20 weeks of job-protected, paid medical leave, or up 26 weeks of combined family and medical leave in a benefit year.
If eligible, you can receive benefit payments for up to eight weeks. Payments are about 60 to 70 percent of your weekly wages earned 5 to 18 months before your claim start date. You will receive payments by debit card or check it's your choice!
To be eligible for FMLA benefits, an employee must:work for a covered employer;have worked for the employer for a total of 12 months;have worked at least 1,250 hours over the previous 12 months; and.work at a location where at least 50 employees are employed by the employer within 75 miles.
If eligible, you can receive benefit payments for up to eight weeks. Payments are about 60 to 70 percent of your weekly wages earned 5 to 18 months before your claim start date. You will receive payments by debit card or check it's your choice!
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You and your health care provider must fill out this form about your serious health condition. For serious health conditions, ask your or your family member's healthcare provider to complete the appropriate Certification of Healthcare Provider (CHP) form.