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DI / DE 2572
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SAMPLE
, this page for reference only
Report of Re-established Paid Family Leave Claim
Mailing Date:
Blank Line
Last four digits of Claimant
SSN
:
Blank Line
Claimant Name:
Blank Line
CED
:
Blank Line
The Report of Voluntary Plan Family Leave (VPFL) Claim that was submitted for the above-referenced claimant is a re-established claim within a
12
-month benefit period. The initial Claim Effective Date for this benefit period was
Blank Line
.
The Paid Family Leave (PFL) weekly benefit amount for this benefit period is
Blank Line
.
So that benefits can be properly determined and paid on the submitted Voluntary Plan Paid Family Leave (VPFL) claim, please take note of the following:
One or more valid
PFL
claims were filed within the
12
-month benefit period. See attached payment history records.
One or more valid
VPFL
claims were filed with other employers within the
12
-month benefit period. You must obtain additional information about these claims from the claimant.
If you have any questions or concerns, please call the
PFL
office at
1-877-238-4373
.
cc:
Blank space
DE 2572 Rev. 1 (8-21)
(INTRANET)
SAMPLE
, this page for reference only
Report of Re-established Paid Family Leave Claim
Mailing Date:
MM/DD/YYYY
Last four digits of Claimant
SSN
:
XXXX
Claimant Name:
Blank Line
CED
:
MM/DD/YYYY
The Report of Voluntary Plan Family Leave (VPFL) Claim that was submitted for the above-referenced claimant is a re-established claim within a
12
-month benefit period. The initial Claim Effective Date for this benefit period was
MM/DD/YY
.
The Paid Family Leave (PFL) weekly benefit amount for this benefit period is
Blank Line
.
So that benefits can be properly determined and paid on the submitted Voluntary Plan Paid Family Leave (VPFL) claim, please take note of the following:
One or more valid
PFL
claims were filed within the
12
-month benefit period. See attached payment history records.
One or more valid
VPFL
claims were filed with other employers within the
12
-month benefit period. You must obtain additional information about these claims from the claimant.
If you have any questions or concerns, please call the
PFL
office at
1-877-238-4373
.
DE 2572 Rev. 1 (8-21)
(INTRANET)
SAMPLE
, this page for reference only
Report of Re-established Paid Family Leave Claim
Mailing Date:
MM/DD/YYYY
Last four digits of Claimant
SSN
:
XXXX
Claimant Name:
Blank Line
CED
:
MM/DD/YYYY
The Report of Voluntary Plan Family Leave (VPFL) Claim that was submitted for the above-referenced claimant is a re-established claim within a
12
-month benefit period. The initial Claim Effective Date for this benefit period was
MM/DD/YY
.
The Paid Family Leave (PFL) weekly benefit amount for this benefit period is
Blank Line
.
So that benefits can be properly determined and paid on the submitted Voluntary Plan Paid Family Leave (VPFL) claim, please take note of the following:
One or more valid
PFL
claims were filed within the
12
-month benefit period. See attached payment history records.
One or more valid
VPFL
claims were filed with other employers within the
12
-month benefit period. You must obtain additional information about these claims from the claimant.
If you have any questions or concerns, please call the
PFL
office at
1-877-238-4373
.
cc:
Blank space
File Copy
DE 2572 Rev. 1 (8-21)
(INTRANET)
Email Address:
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