Your name
(Required)
First
Last
Email
(Required)
Enter the email that you used to create your PFML employer account
Company name
(Required)
Company EIN
(Required)
Enter your organization's 9 digit Employer Identification Number (EIN) with no dashes
MTC PFML Account Number
(Required)
Enter the number beginning with PFM. You can log into your MassTaxConnect account to see this number.
What date does your current exemption end?
What type of exemption are you requesting or renewing?
Purchased plan
Self-insured plan
List the name of your insurance provider