Ct pl certification for serious health condition form

When uploading identity verification documents, select Identification as document type.

Please submit one stand-alone document OR two alternate documents.

Stand-Alone Documents

The easiest way to provide proof of identity is a color copy of both front and back of your Connecticut driver's license or state issued non-driver ID.

If you do not have a Connecticut driver's license or state issued non-driver ID, you will need to provide ONE of the following documents:

Valid government issued form of identification (i.e., passport, passport card, ID card, enhanced or standard driver’s license)

• Form I-766 Employment Authorization
• Form I-551 Permanent Resident Card

Valid foreign government issued form of identification (i.e., passport, consular ID card, national identification card)

Alternate Documents

If you do not have one of the stand-alone identity verification documents, provide one of the documents in Group A and one of the documents in Group B.

Group A

Certified copy of your birth certificate filed with a State Office of Vital Statistics or equivalent agency in your state of birth

Certificate of Citizenship, Form N-560, or Form N-561, issued by Department of Homeland Security (DHS)

Group B

Authorization letter from the Internal Revenue Service (IRS) displaying your 9-digit individual tax identification number

Employment Verification (REQUIRED)

Are you a Sole Proprietor/Self-Employed Individual?

Employment Verification Form

The Employment Verification Form is included in your Notice of Application and has the case number and name pre-filled.

1. Provide this form to your employer.
2. Your employer must complete and return the form to Aflac within 10 days.
3. Your employer may return the form directly to Aflac, or they may return it to you to upload through the CT Paid Leave Aflac portal.
4. Follow up with your employer to ensure that the Employment Verification Form has been completed and returned to Aflac.
5. If your employer has questions, they may use the Employment Verification Form Job Aid or contact us.

Sample Forms

When uploading the Employment Verification Form, select:

When uploading documents, do not use the sample forms.

Sole Proprietor/Self-Employed Employment Verification Form

The Sole Proprietor/Self Employed Employment Verification form is included in your Notice of Application and has the case number and name pre-filled.

• You must complete and return the form to Aflac within 10 days.
• For additional assistance, view our Sole Prop/Self Employed Employment Verification Form Job Aid or contact us.

Sample Forms

When uploading the Sole Proprietor/Self Employed Employment Verification form, select:

When uploading documents, do not use the sample forms.

If you are still having trouble getting your employer to complete and return the form, call Aflac (877-499-8606) for guidance.

Important

Important

• All employers, even if you are not taking leave from them all
• Former employers, even if you are no longer employed with that employer

Documents supporting the leave reason (REQUIRED)

Different documents are required depending on your leave reason.

Your Notice of Application will include the required documents, many of which are pre-filled with your name and case number.

If you lost these forms, log into the CT Paid Leave Aflac Portal to download your Notice of Application with the pre-filled forms.

My own serious health condition

I am experiencing a serious health condition

Your leave reason is either your own injury or illness, organ donation or bone marrow donation.

Certification for Serious Health Condition

The Certification for Serious Health Condition is included in your Notice of Application and has the case number and name pre-filled.

• Complete the "Applicant Information", "Employer Information" and "What is the Paid Leave for?" sections at the top of the form.
• Then, provide this form to your healthcare provider to complete the remaining sections of the form.
• Your healthcare provider may return the form directly to Aflac, or they may return it to you to upload through the CT Paid Leave Aflac portal. This form must be returned to Aflac within 15 days.
• Your healthcare provider cannot charge a fee to fill out this form under Connecticut law, C.G.S. 31-49r(e)
• Date of illness or incapacity must have an actual start and end date. These dates can be estimated and updated later. Entering "To be determined" or "Unknown" is likely to cause the application to be delayed or denied.
• Follow up with your healthcare provider to ensure that the Certification for Serious Health Condition has been completed and returned to Aflac.
• We will accept fully completed FLMA medical documentation as an alternative to the CT Paid Leave Medical Certification.

If you are having trouble getting your healthcare provider to complete and return the forms, call Aflac (877-499-8606) for guidance

Sample Forms

When uploading the Certification for Serious Health Condition, select:

When uploading documents, do not use the sample forms.

Starting or expanding my family - Pregnancy/childbirth

Your leave reason is pregnancy/childbirth

This leave is taken by the pregnant parent during their pregnancy or to recover from the delivery.

Certification for Serious Health Condition

The Certification for Serious Health Condition is included in your Notice of Application and has the case number and name pre-filled.

• Complete the "Applicant Information", "Employer Information" and "What is the Paid Leave for?" sections at the top of the form.
• Then, provide this form to your healthcare provider to complete the remaining sections of the form.
• Your healthcare provider may return the form directly to Aflac, or they may return it to you to upload through the CT Paid Leave Aflac portal. This form must be returned to Aflac within 15 days.
• Your healthcare provider cannot charge a fee to fill out this form under Connecticut law, C.G.S. 31-49r(e)
• Date of illness or incapacity must have an actual start and end date. These dates can be estimated and updated later. Entering "To be determined" or "Unknown" will result in the application being denied.
• Follow up with your healthcare provider to ensure that the Certification for Serious Health Condition has been completed and returned to Aflac.
• We will accept fully completed FLMA medical documentation as an alternative to the CT Paid Leave Medical Certification.

If you are having trouble getting your healthcare provider to complete and return the forms, call Aflac (877-499-8606) for guidance.

Sample Forms

When uploading the Certification for Serious Health Condition, select:

When uploading all other supporting bonding documentation, select:

When uploading documents, do not use the sample forms.

Starting or expanding my family - Childbirth bonding

Your leave reason is childbirth bonding.

This leave is taken by a worker to bond after the birth of their child. Bonding leave can be taken by both parents.

Bonding Statement

• The Bonding Statement is included in your Notice of Application and has the case number and name pre-filled.
• You must complete a CT Paid Leave Bonding Statement and submit appropriate supporting documentation as listed in the Bonding Statement.

Supporting documentation for a biological child:

• CT Paid Leave Certification of Birth; or
• Copy of Hospital Discharge document (accepted only if it includes the name of the applicant); or
• Copy of the child's Birth Certificate

Sample Forms

When uploading the Bonding Statement:

When uploading all other supporting bonding documentation, select:

When uploading documents, do not use the sample forms.

Starting or expanding my family - Adoption or foster care placement/bonding

Your leave reason is adoption or foster care placement/bonding

This leave is taken by a worker to attend to activities needed to process the child's adoption or foster care placement and/or to bond with the child after the adoption or placement.

Bonding Statement

• The Bonding Statement is included in your Notice of Application and has the case number and name pre-filled.
• You must complete a CT Paid Leave Bonding Statement and submit appropriate supporting documentation as listed in the Bonding Statement.

Supporting documentation depends upon the type of bonding:

• Adopted child
  • Copy of adoption papers or court documents that includes child's date of birth and adoption date.
  • Copy of child's foster care papers or a court document that includes child's date of birth and date(s) of placement.

  Sample Forms

  

  When uploading the Bonding Statement select:

  Document Type:
  Bonding Certification Form

  

  When uploading all other supporting bonding documentation, select:

  Document Type:
  Proof of Birth

  When uploading documents, do not use the sample forms.

  Caring for a Family Member

  I need to care for a family member experiencing a serious health condition

  You are caring for a family member who is receiving treatment for or recovering from a serious health condition or is recovering from childbirth. A family member means:

  • your spouse
  • your child (of any age)
  • your parent or spouse's parent
  • your grandparent or spouse’s grandparent
  • your grandchild (of any age)
  • sibling or spouse's sibling or sibling's spouse
  • an individual related to you by blood or affinity whose close association with you is the equivalent to one of the listed family relationships

  Statement of Family Relationship

  • The Statement of Family Relationship is included in your Notice of Application and has the case number and name pre-filled.
  • You must complete a CT Paid Leave Statement of Family Relationship.

  Sample Forms

  Certification for Care of A Family Member with a Serious Health Condition

  The Certification for Care of A Family Member with a Serious Health Condition is included in your Notice of Application and has the case number and name pre-filled.

  • Complete the "Applicant Information", "Who is the Paid Leave for?", "Family Member's Information", and "Family Member's Health Care Provider Information" sections at the top of the form.
  • Then, provide this form to your family member's healthcare provider to complete the remaining sections of the form.
  • Your family member's healthcare provider may return the form directly to Aflac, or they may return it to you to upload through the CT Paid Leave Aflac portal. This form must be returned to Aflac within 15 days.
  • Your family member's healthcare provider cannot charge a fee to fill out this form under Connecticut Law C.G.S. 31-49r(e).
    
    • Date of illness or incapacity must have an actual start and end date. These dates can be estimated and updated later. Entering "To be determined" or "Unknown" will result in the application being denied.
    • Follow up with your family member's healthcare provider to ensure that the Certification for Care of A Family Member with a Serious Health Condition has been completed and returned to Aflac.
    • We will accept fully completed FLMA medical documentation as an alternative to the Certification for Care of A Family Member with a Serious Health Condition.

    If you are having trouble getting your family member's healthcare provider to complete and return the forms, call Aflac (877-499-8606) for guidance.

    Sample Forms

    

    When uploading the Statement of Family Relationship, select:

    Document Type:
    Family Relationship Form

    Certification for Care of a Family Member with a Serious Health Condition form" />

    When uploading the Certification for Care of A Family Member with a Serious Health Condition, select:

    Document Type: Caregiver Certification Form

    When uploading documents, do not use the sample forms.

    Military Caregiver

    I need to take military family leave

    Military family leave can be taken for military caregiver leave or for qualifying exigency leave.

    You are caring for family member who is a Current Service Member and who is experiencing a serious illness or injury incurred in the line of duty on active duty.

    Certification for Serious Injury or Illness of a Current Service Member for Military Caregiver Leave

    • The Certification for Serious Injury or Illness of a Current Service Member for Military Caregiver Leave is included in your Notice of Application and has the case number and name pre-filled.
    • You and the healthcare provider of your military family member must complete this form.
    • We will accept one of the following as an alternative to Certification for Serious Injury or Illness of a Current Service Member for Military Caregiver Leave:
      • Fully completed FLMA medical documentation (Form WH-385)
      • Copy of an ITA (Invitational Travel Authorization)
      • Copy of an ITO (Invitational Travel Order)

      Sample Forms

      

      When uploading the Certification for Serious Injury or Illness of a Current Service Member for Military Caregiver Leave or the Form WH-385, select:
      

      Document Type:
      Caregiver Certification Form

      

      When uploading the copy of an ITA (Invitational Travel Authorization) or ITO (Invitational Travel Order), select:

      Document Type:
      Military Orders

      When uploading documents, do not use the sample forms.