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The Department has developed optional-use forms which can be used by employers to provide required notices to employees, and by employees to provide certification of their need for leave for an FMLA qualifying reason. These forms are electronically fillable PDFs and can be saved electronically.
The FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave.
Forms. Claim for Paid Family Leave (PFL) Benefits (DE 2501F) - English: You must submit an original form provided by the EDD. This form cannot be downloaded or reproduced. To submit the DE 2501F electronically, visit How to File a Paid Family Leave Claim in SDI Online.
The Family and Medical Leave Act (FMLA) provides certain employees with up to 12 weeks of unpaid, job-protected leave per year. It also requires that their group health benefits be maintained during the leave.
FMLA grants up to 12 workweeks per year of unpaid leave for the following reasons: caring for your spouse, parent, or child with a serious health condition; bonding with a newborn, adopted child, or foster child; addressing and recovering from your own serious health condition, including pregnancy;
FMLA and CFRA help to protect your job while you are receiving Disability Insurance or Paid Family Leave benefits when you must: Take medical leave for yourself. Care for a family member who is seriously ill. Bond with a new child.
The department listed below is requesting the information specified on this form: Department/Division The information collected will be used for purposes of determining your eligibility for FMLA/CFRA/PDL
