Employer Request to Switch from a Private Plan to the Commonwealth's PFML program
Employer Information
Employers Tax Identification Number
(Required)
This is the number provided to the Commonwealth. This is the Employer Identification Number (EIN). Do NOT include dashes.
Employer Name
(Required)
Contact Information
Please provide contact information for the individual who can answer any questions about your request to opt back into PFML.
Name
(Required)
First Name
Last Name
Title
(Required)
Phone
(Required)
Email
(Required)
Private Plan Information
Effective date of exemption
(Required)
MM slash DD slash YYYY
The date the business was initially approved for an exemption.
I am opting back into the PFML for
(Required)
Family and Medical
Family Only
Medical Only
Desired effective date for opting back into PFML State Plan
(Required)
MM slash DD slash YYYY
You may only opt into the state plan at the beginning of a quarter (i.e. January 1, April 1, July 1, or October 1)
Leave Administrator
An employer must have a registered leave administrator with DFML. A leave administrator is the person responsible for reviewing and processing employee claims on behalf of an organization. Please provide information for the individual who will be responsible for reviewing employee claims.
Name
(Required)
First Name
Last Name
Title
(Required)
Email
(Required)
This must be their work email address.
Leave Administrator Verification
In order to verify your account, you will need to work with the person or organization that is registered to manage your MassTaxConnect account to obtain your MassTaxConnect PFM account number.
MassTaxConnect PFM Account Number
(Required)
PFM-00000000-000
Attestation
By submitting this request, I represent and acknowledge that, in my capacity that I am authorized to make this change. I further understand and acknowledge that the employer listed above may be responsible for PFML contributions retroactive to the effective date of the private plan exemption if the exemption was not in effect for at least four consecutive quarters prior to the effective date of this change. Furthermore, I acknowledge and understand that the Employer may not collect retroactive contributions from employees to satisfy this requirement. The employer agrees to notify all of its employees in writing within thirty (30) days of the effective date listed above that they will be covered under the Paid Family and Medical Leave plan provided by the state. Additionally, I acknowledge and understand that the individual(s) designated as a “Leave Administrator” for the employer will have the authority to review and manage PFML applications for the employer’s workforce.
Name
(Required)
First Name
Last Name
Title
(Required)
I hereby attest that this information is true, accurate and complete to the best of my knowledge.
(Required)
Yes