EOLWD-DFML

Employer request to make a change in PFML exemption status

Employer Information

Employer Name(Required)

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 mailing address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Information

Please provide contact information for the individual who can answer any questions about your request.

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.

Exemption type(Required)

Self-Insured

Purchased

Coverage type(Required)

Family and Medical

Family Only

Medical Only

Change Request

What type of change are you requesting to your exemption status? (select one)

Learn more about requirements for purchased plans and requirements for self-insured plans.

Employer dissolution

Employer merger

Change of insurance carrier

Change from purchased plan to self-insured plan

Change from self-insured to purchased plan

Ending exemption to opt into the PFML state program

Employer dissolution

What is the effective date of the dissolution?(Required)

Attach articles of dissolution(Required)

Drop files here or

Max. file size: 5 MB, Max. files: 1.

Employer merger

What is the effective date of the merger?(Required)

New business EIN

The name and Federal Employer Identification Number (FEIN) of any acquiring or affiliate organization that will be assuming the employees and covered contract employees affected by the dissolution, acquisition or merger.

Name of new business(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Attach articles of merger(Required)

Drop files here or

Max. file size: 5 MB, Max. files: 1.

Change of insurance carrier

New carrier name(Required)

What is the effective date of the policy from the new carrier?(Required)

Attach confirmation of insurance form(Required)

Drop files here or

Max. file size: 5 MB, Max. files: 1.

Change from purchased to self-insured plan

Learn more about requirements for self-insured plans.

Attach a self-insured insurance declaration document(Required)

Drop files here or

Max. file size: 5 MB, Max. files: 1.

Attach a copy of your surety bond(Required)

Drop files here or

Max. file size: 5 MB, Max. files: 1.

Change from self-insured to purchased plan

Learn more about requirements for purchased plans.

Insurance carrier name(Required)

What is the effective date of the policy from the new carrier?(Required)

You may only begin a new plan at the beginning of a quarter (i.e. January 1, April 1, July 1, or October 1)

January 1

April 1

July 1

October 1

Year(Required)

Attach confirmation of insurance form(Required)

Drop files here or

Max. file size: 5 MB, Max. files: 1.

Ending exemption to switch to state plan

Mass Tax Connect PFM number(Required)

An employer must have a registered leave administrator with DFML. The designated leave administrator must create an employer account and will be asked to enter an email address and password. Learn how to create a leave administrator account if you do not already have one.

What is the effective date for the switch to the state plan?(Required)

You may only begin a new plan at the beginning of a quarter (i.e. January 1, April 1, July 1, or October 1)

January 1

April 1

July 1

October 1

Year(Required)

Attestation

By submitting this request, I represent and acknowledge that I am acting in my capacity as representative of the employer listed above (the “Employer”) and that I am authorized by the Employer to make this change. I further understand and acknowledge that if the Employer terminates their private plan prior to completing the initial exemption term of four (4) consecutive calendar quarters then the Employer may be responsible for PFML contributions retroactive to the effective date of the private plan exemption. 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 of any changes in their paid leave application process.

Name(Required)

First Name Last Name

Title(Required)