EOLWD-DFML

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)

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)

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)