This report is being submitted on behalf of
(Required)
An Insurance Carrier
A Self-Insured Employer
Insurance Carrier
Please list the full name of the reporting approved private plan insurer.
Insurance Carrier
(Required)
Self-Insured Employer
Please list the full name of the reporting employer or covered business entity, as well as the employer identification number (EIN). If a third party administrator is used to manage all or part of a paid family and/or medical leave plan, the third party administrator’s information must be listed. If you are a self insured employer or a third party administrator for a self insured employer submitting a report for multiple entities, please submit only one report with aggregated data and list all of the separate EIN's below. Do not submit the same report multiple times.
Business Name
(Required)
Employer Identification Number
(Required)
Do you use a third party admin
(Required)
Yes
No
Third Party Admin
(Required)
Third Party Admin Point of Contact Name
(Required)
First Name
Last Name
Third Party Admin Point of Contact Email
(Required)
Contact Information
List contact information for a primary contact person and secondary contact person at the reporting employer or covered business entity. One or both of these individuals may be contacted to provide additional information or to verify reported information.
Primary Point of Contact
(Required)
First Name
Last Name
Primary Point of Contact Title
(Required)
Primary Point of Contact Email
(Required)
Primary Point of Contact Phone Number
(Required)
Secondary Point of Contact Name
(Required)
First Name
Last Name
Secondary Point of Contact Title
(Required)
Secondary Point of Contact Email
(Required)
Secondary Point of Contact Phone Number
Attachment
Attach the paid family and medical leave activity report for the reporting employer or insurance carrier for the 2025 fiscal year, which spans July 1, 2024 to June 30, 2025. Ensure that all required fields are completed.
File
(Required)
Drop files here or
Select files
Accepted file types: xls, xlsx, csv, Max. file size: 50 MB.
Attestation
I represent and acknowledge that I am authorized to submit the required data on behalf of the employer listed above, and attest that this information is true, accurate and complete to the best of my knowledge, presented in the manner requested by the DFML.
Attestation
(Required)
Yes
Name
(Required)
First Name
Last Name
Title
(Required)
Company
(Required)