CFML Initial Intake Form

- Fam/Med Leave
  - CFML Initial Intake Form

CFML Initial Intake Form
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- Please use this form to notify the Benefits Department of your intent to file a claim for CFML benefits.
- Employee Name REQUIRED Please fill out this field. Please enter valid data.
- Person submitting this form if not the employee (business manager/manager/supervisor/payroll contact) Please enter valid data.
- Employer Name and City/Town REQUIRED Please fill out this field. Please enter valid data.
- Preferred Phone Number While on Leave REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Preferred E-Mail Address While on Leave REQUIRED Please fill out this field. Please enter valid data.
- Job Title/Position REQUIRED Please fill out this field. Please enter valid data.
- Reason for Requesting CFML Benefits REQUIRED Please fill out this field.
- Do you expect to receive any additional payments during this time? For example, Worker's Compensation, AFLAC, or other short-term disability. REQUIRED Please fill out this field.
- Have you notified your manager/supervisor/payroll contact at your location of this request for CFML benefits? REQUIRED Please fill out this field.
- The Benefits Department will coordinate closely with location administrators to ensure they are aware of potential CFML claims when contacted.
- Expected date of incapacitation REQUIRED Please fill out this field. Please enter a date.
- Expected length of absence REQUIRED Please fill out this field. Please enter valid data.
- Do you intend to return to work following the conclusion of your leave? REQUIRED Please fill out this field. Please enter valid data.
- CFML benefits are only available for employees who return to work at the end of their approved leaves. The CFML program reserves the right to pursue repayments from employees who receive benefit payments and then do not return to work.
- Have you requested/taken a leave of absence for your own or a family member's serious health condition in the past 12 months? REQUIRED Please fill out this field.
- If you answered yes to the prior question, please indicate the dates of leave. Please enter valid data.
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