Massachusetts Application for Family Medical Leave of Absence

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Multi-State
Control #:
US-425EM
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Description

This form may be used by an employee to request leave under the FMLA.
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FAQ

Qualifying reasons for which an employee can take FMLA or PFML leave include:Birth, adoption, or placement of a foster child.For a serious health condition that makes the employee unable to perform the essential functions of their job.To care for a family member with a serious health condition.More items...

You can take your leave 3 ways: continuous, intermittent, or reduced. If you are applying for military-related paid family leave benefits, or if you are currently self-employed or unemployed, please call the Department's Contact Center at (833) 344-7365 to begin your application.

If you are applying for military-related paid family leave benefits, or if you are currently self-employed or unemployed, please call the Department's Contact Center at (833) 344-7365 to begin your application.

To apply for FMLA, the employee must take an FMLA Medical Certification Form to their health care provider. This form ensures that the employee's or family member's applicable health condition is valid. After receiving the form, the employee must return it within 15 calendar days.

MA Paid Family & Medical Leave Benefit Amounts 80% of the portion of the employee's average weekly wage that is equal to or less than 50% of the State average weekly wage (SAWW); Plus 50% of the portion of the employee's average weekly wage that is more than 50% of the SAWW; Capped at the Maximum Weekly Benefit.

Benefits Provided FMLA provides up to 12 weeks of job-protected, unpaid leave in a calendar year for family or medical reasons, or up to 26 weeks of job-protected, unpaid leave in a calendar year to care for a family member in the armed services. Employers are not required to pay employees taking FMLA leave.

In most circumstances, FMLA and PFML will run concurrently if the employee is eligible for both types of leave. The leave can be taken intermittently for up to 12 weeks per benefit year.. While on leave, employees will have their health insurance maintained at the same level as if they had not been on leave.

You're eligible for PFML coverage if you are:A full-time, part-time, or seasonal employee in Massachusetts. A 1099-MISC contractor who works for a business that issues 1099-MISC tax forms to more than 50% of its employees. Unemployed for 26 weeks or fewer.

When the Department has enough information to consider your application complete, they will begin review and make a decision within 14 calendar days.

Who's eligible for Paid Family and Medical Leave? The PFML law covers most employees who have earned at least $5,700 over the past 4 calendar quarters. In addition, you must have earned at least 30 times the benefit amount that you are eligible for. If you are self-employed, you may opt in through MassTaxConnect.

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Massachusetts Application for Family Medical Leave of Absence