Request for Retroactive PFML Private Plan Exemption
Employer Information
Employer Name
(Required)
Employer Tax Identification Number
(Required)
This is the Employer Identification Number (EIN). Do NOT include dashes.
MassTaxConnect PFM Account Number
(Required)
PFM-00000000-000
Private Plan Information
What type of plan does the business have?
(Required)
Purchased Private Plan
Self-Insured Private Plan
Which Insurance Carrier cover the business for Paid Family and Medical Leave during the time you are requesting a retroactive exemption for?
(Required)
I am requesting a Private Plan Exemption back to
(Required)
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The date the business missed filing their PFML private plan exemption.
What was the average workforce count in 2022?
(Required)
What was the average workforce count in 2023?
(Required)
What was the average workforce count in 2024?
(Required)
Please add any information that may be relevant to this request.
Contact Information
Please provide contact information for the individual at the employer DFML should contact if we need more information. Do not provide a contact for the insurance carrier.
Name
(Required)
First Name
Last Name
Title
(Required)
Phone
(Required)
Email
(Required)
Attachments
Documentation demonstrating that the employer notified its employees of the private plan coverage and the effective date of plan coverage
(Required)
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Max. file size: 50 MB.
Documentation from your insurance carrier showing signatures predating the effective date and confirming the date of coverage.
(Required)
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Max. file size: 50 MB.
A signed letter on company letterhead explaining why the employer failed to submit a private plan exemption application on time for the intended effective date. This letter should also include a confirmation from the employer that all of the employer’s affiliated entities and subsidiaries have separately filed for an exemption and are all included in the private plan provided by their carrier.
(Required)
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Max. file size: 50 MB.
A signed letter from your insurance carrier(s) indicating when their coverage commenced confirming that there are no gaps in coverage where there has been a transition between private plans or a transition from the state plan to the private. If applicable, this letter should include all entities that are or were covered under the policy and the date that coverage began for each unique entity.
(Required)
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Max. file size: 50 MB.
Surety Bond running to the Commonwealth of Massachusetts in an amount based upon the size of its Massachusetts workforce on the designated form approved by the Department.
(Required)
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Max. file size: 50 MB.
The Paid Family and/or Medical Leave Private Plan Policy
(Required)
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Max. file size: 50 MB.
A signed letter on company letterhead explaining why the employer failed to submit a private plan exemption application on time for the intended effective date. This letter should also include a confirmation from the employer that all of the employer’s affiliated entities and subsidiaries have separately filed for an exemption and are all included in the private plan provided by their carrier.
(Required)
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Max. file size: 50 MB.
Additional Documentation
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Max. file size: 50 MB.
Additional Documentation
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Max. file size: 50 MB.
Attestation
I represent and acknowledge that I am authorized to represent and make this request on behalf of the employer listed above, and attest that this information is true, accurate and complete to the best of my knowledge. I understand and acknowledge that (1) the employer listed above may be responsible for PFML contributions retroactive to the effective date of the private plan policy if the retroactive exemption request is not approved, and (2) that the employer may not collect retroactive contributions from employees to satisfy in whole or in part such a responsibility to pay PFML contributions retroactive to the effective date of the private plan policy. I authorized the Department of Family and Medical Leave to contact the insurance carrier(s) I listed above, if any.
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.
Yes