As a Massachusetts employer, you are required to inform your Massachusetts employees and covered contract workers about their rights and obligations under the Massachusetts Paid Family and Medical Leave (PFML) law. To do so, you may provide this form to your employees and covered contract workers. You may also create or use a different notice of your choosing as long as the notice you use provides the same information as required by law.
This form is for employers who have 25 or more Massachusetts employees and covered contract workers. If you have less than 25 Massachusetts employees and covered contract workers, please use the Employer notice for a workforce with fewer than 25 covered individuals form. Likewise, if you engage with self-employed individuals who are not covered contract workers, you may provide them the Employer notice to self-employed individuals for a workforce with fewer than 25 covered individuals form to notify them of their option to elect coverage for themselves.
To use this form, first complete:
- The chart on page 2 indicating whether you have an approved private plan;
- The chart on page 5 indicating what percentage of the employee contribution will be deducted from your employees’ wages, and what percentage (if any) you will pay;
- The employer information chart on page 6;
- The check boxes on page 6 indicating where employees can find information on your private plan, if any. (Check N/a if you are participating in the state Trust Fund.)
Once you have filled out these sections, provide pages 2-6 of this form to your employees and covered contract workers for them to review and sign.
As a Massachusetts employer, you are required to inform your Massachusetts employees and covered contract workers about their rights and obligations under the Massachusetts Paid Family and Medical Leave (PFML) law. To do so, you may provide this form to your employees and covered contract workers. You may also create or use a different notice of your choosing as long as the notice you use provides the same information as required by law.
This form is for employers who have 25 or more Massachusetts employees and covered contract workers. If you have less than 25 Massachusetts employees and covered contract workers, please use the Employer notice for a workforce with fewer than 25 covered individuals form. Likewise, if you engage with self-employed individuals who are not covered contract workers, you may provide them the Employer notice to self-employed individuals for a workforce with fewer than 25 covered individuals form to notify them of their option to elect coverage for themselves.
To use this form, first complete:
- The chart on page 2 indicating whether you have an approved private plan;
- The chart on page 5 indicating what percentage of the employee contribution will be deducted from your employees’ wages, and what percentage (if any) you will pay;
- The employer information chart on page 6;
- The check boxes on page 6 indicating where employees can find information on your private plan, if any. (Check N/a if you are participating in the state Trust Fund.)
Once you have filled out these sections, provide pages 2-6 of this form to your employees and covered contract workers for them to review and sign.
PAID FAMILY AND MEDICAL LEAVE NOTICE TO EMPLOYEES (25 or more Workers)
Employer Name:
Employer EIN:
Please read this notice carefully. It contains important information about your rights, obligations, and eligibility under the Massachusetts Paid Family and Medical Leave law. Please keep this notice for your records.
The Massachusetts Paid Family and Medical Leave (PFML) law provides most Massachusetts employees the right to paid family and medical leave. These rights are described further below and include both (1) job protection when the employee returns to work and (2) partial wage-replacement benefits while the employee is out of work. Employers can provide these benefits either by (1) participating in the PFML Trust Fund operated by the Massachusetts Department of Family and Medical Leave (DFML), or (2) providing an exempt private plan that offers benefits at least as generous as those available through the Department.
An employer may apply for an exemption from the medical leave contribution, family leave contribution, or both. Your employer has elected to provide benefits as follows:
Does not have an approved private plan and is providing all leave benefits through the DFML;
Has an approved private plan for both family and medical leave benefits;
Has an approved private plan for family leave benefits only, and is providing medical leave benefits through the DFML;
Has an approved private plan for medical leave benefits only, and is providing family leave benefits through the Department.
(Private Plan Name)
(Private Plan Contact Information)
Regardless of whether your employer participates in the state Trust Fund or has a private plan, you will be entitled to certain benefits and protections. You may be required to make contributions to the Trust Fund or to fund your employer’s private plan, but only up to a certain amount. You will also need to tell your employer when you need leave, and you will need to file a claim for benefits with the Department or through your employer’s private plan.
- Explanation of Benefits
Leave Allotments. Under the PFML Law, you may be entitled to up to:
- 12 weeks of paid family leave in a benefit year for the birth, adoption, or foster care placement of a child; to care for a family member with a serious health condition; or because of a qualifying exigency arising out of the fact that a family member is on active duty or has been notified of an impending call to active duty in the Armed Forces;
- 20 weeks of paid medical leave in a benefit year if they have a serious health condition that incapacitates them from work;
- 26 weeks of paid family leave in a benefit year to care for a family member who is a covered service member undergoing medical treatment or otherwise addressing consequences of a serious health condition relating to the family member’s military service;
- 26 total weeks, in the aggregate, of paid family and medical leave in a single benefit year.
A “benefit year” is the 12 months preceding the Sunday immediately before your leave begins.
Other Leaves. Any leave you take – paid or unpaid – for the same qualifying reasons listed above will count towards your amount of leave for that benefit year.
Eligibility. You will be eligible for leave and wage-replacement benefits if you meet the earnings test. You must have earned at least $6,000 in wages in Massachusetts in the four completed quarters before you apply for benefits. In the same period, you also must have earned at least 30 times your maximum potential benefit amount. (This is the amount calculated in the “Wage Replacement Payments” section below.)
Wage Replacement Payments. When you take leave for any of the reasons described above, you will be eligible to apply to the Department or to your employer’s private plan for wage replacement benefits. These benefits will be a proportion of your average weekly earnings. Your maximum potential benefit amount will be as follows:
- 80% of earnings up to 50% of the State Average Weekly Wage
- 50% of earnings above the State Average Weekly Wage
- In no event more than a maximum amount. For 2023, this maximum benefit amount is $1,129.82. This amount will be adjusted annually based on increases in the State Average Weekly Wage.
Private plans may choose to provide higher benefits but may not provide lower amounts than what the Department would pay.
Concurrent Benefits Payments. If you receive benefits from other sources while you are also receiving benefits from the Department, the benefits you receive from the Department may be
- Explanation of Benefits
Leave Allotments. Under the PFML Law, you may be entitled to up to:
- 12 weeks of paid family leave in a benefit year for the birth, adoption, or foster care placement of a child; to care for a family member with a serious health condition; or because of a qualifying exigency arising out of the fact that a family member is on active duty or has been notified of an impending call to active duty in the Armed Forces;
- 20 weeks of paid medical leave in a benefit year if they have a serious health condition that incapacitates them from work;
- 26 weeks of paid family leave in a benefit year to care for a family member who is a covered service member undergoing medical treatment or otherwise addressing consequences of a serious health condition relating to the family member’s military service;
- 26 total weeks, in the aggregate, of paid family and medical leave in a single benefit year.
A “benefit year” is the 12 months preceding the Sunday immediately before your leave begins.
Other Leaves. Any leave you take – paid or unpaid – for the same qualifying reasons listed above will count towards your amount of leave for that benefit year.
Eligibility. You will be eligible for leave and wage-replacement benefits if you meet the earnings test. You must have earned at least $6,000 in wages in Massachusetts in the four completed quarters before you apply for benefits. In the same period, you also must have earned at least 30 times your maximum potential benefit amount. (This is the amount calculated in the “Wage Replacement Payments” section below.)
Wage Replacement Payments. When you take leave for any of the reasons described above, you will be eligible to apply to the Department or to your employer’s private plan for wage replacement benefits. These benefits will be a proportion of your average weekly earnings. Your maximum potential benefit amount will be as follows:
- 80% of earnings up to 50% of the State Average Weekly Wage
- 50% of earnings above the State Average Weekly Wage
- In no event more than a maximum amount. For 2023, this maximum benefit amount is $1,129.82. This amount will be adjusted annually based on increases in the State Average Weekly Wage.
Private plans may choose to provide higher benefits but may not provide lower amounts than what the Department would pay.
Concurrent Benefits Payments. If you receive benefits from other sources while you are also receiving benefits from the Department, the benefits you receive from the Department may be reduced. Certain types of other benefits will cause a one-for-one reduction in benefits you receive from the Department. This means that for each dollar you receive from these benefits, your benefit from the Department will decrease by a dollar. Benefits that will have this effect include:
- Workers’ Compensation
- Unemployment Insurance
- Permanent Disability Policies or Programs
- Extended Illness Leave Bank Leave
Other forms of benefits will not reduce the benefits you receive from the Department unless you are receiving more than your average weekly wage in total benefits. Benefits that will have this effect include:
- Temporary Disability Policies or Programs (including both Short-Term Disability and Long-Term Disability)
- Employer-run Family and/or Medical Leave Policies or Programs
WARNING: TAKING PAID TIME OFF AND PFML. Paid Time Off (PTO) includes sick time, vacation days, or personal days (or any other similar form of paid time off not listed in the section above that you earn over time or at a specific time, like at the start of every calendar year). You can only take PTO while on paid family and medical leave in specific situations:
- During your waiting week, when no benefits are paid;
- In a single, continuous block of time immediately after your waiting week;
- After you take PFML leave.
If you take PTO at any other point while you receive PFML benefits, your benefits will be cancelled.
- Employee Rights and Protections
Job Protection. Generally, if you take family or medical leave, once you return to work, your employer must restore you to your previous position or to an equivalent position, with the same status, pay, employment benefits, length-of-service credit, and seniority as of the date you started your leave. This may not apply if your position was eliminated due to economic reasons unrelated to your use of leave.
Continuation of Health Insurance. Your employer must continue to provide for, contribute to, or otherwise maintain your employment-related health insurance benefits, if any, at the level and under the conditions coverage would have been provided if you had continued working continuously for the duration of your leave. Your employer may require you to continue to pay your portion of your health insurance premium on the same terms and conditions as before your leave.
No Retaliation. It is unlawful for any employer to discriminate or retaliate against you for exercising any right to which you are entitled under the paid family and medical leave law. An
Effective Rates: 2024
For employers with 25 or more employees
| Family Leave Contribution | Medical Leave Contribution | Total Contribution Amount |
| .18% | .70% | .88% |
Employers are responsible for sending contributions to the DFML for all employees. In 2024, the total contribution amount is 00.88% of wages.
Under the law, employers are responsible for a minimum of 60% of the medical leave contribution (.42% of wages) but are permitted to deduct from employees’ wages up to 40% of the medical leave contribution (.28% of wages) and up to 100% of the family leave contribution (.18% of wages).
| Medical Leave | Total Required Contribution: .70% | |||||
| will contribute | ___%
|
of the medical leave contribution | ||||
| (Employer Name) | and the remaining | ___%
|
will be deducted from your earnings | |||
| Family Leave | Total Required Contribution: .18% | |||||||||||||||||||||||||||||||||||||||||||||
| will contribute | ___%
|
of the family leave contribution | ||||||||||||||||||||||||||||||||||||||||||||
| (Employer Name) | and the remaining | ___%
|
will be deducted from your earnings
Effective Rates: 2024
For employers with 25 or more employees
Employers are responsible for sending contributions to the DFML for all employees. In 2024, the total contribution amount is 00.88% of wages.
Under the law, employers are responsible for a minimum of 60% of the medical leave contribution (.42% of wages) but are permitted to deduct from employees’ wages up to 40% of the medical leave contribution (.28% of wages) and up to 100% of the family leave contribution (.18% of wages).
|
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* The numbers provided are through 2023. These rates may be adjusted on an annual basis, effective January 1 of each calendar year.
- Notifying your Employer
BEFORE you take leave or apply for benefits, you MUST notify your employer that you need to take leave. You are required to provide at least 30 days’ notice of your need for leave. If 30 days’ notice is not possible due to circumstances beyond your control, you must provide notice as soon as practicable, and in any event, before you file any application for benefits.
When you notify your employer of your need for leave, you must provide the following information:
- The anticipated start date of leave;
- The anticipated length of the leave;
- The expected date of return from leave;
- Whether you will need intermittent leave (leave taken in separate blocks of two or more) or reduced leave (leave that involves a reduced schedule of fewer hours or days per week), and;
- If you need intermittent or reduced leave schedule, the expected frequency of leave and expected duration of each instance of leave.
If any of this information changes, you must tell your employer as soon as you are aware of the change.
- Filing a Claim
To apply for Paid Family and Medical Leave benefits, you will need the following information about your employer:
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|
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| (Employer Name) | ||
| (Employer Street Address) | ||
| (Employer City, State, Zip) | ||
| (Federal Employer ID Number) (FEIN)
|
If your employer has an exempt private plan, you must file a claim for benefits with the provider of that plan. Your employer must provide you information about the private plan and the application process. Your employer has made that information available:
- As an attachment to this Notice
- Available at
- Other:
- N/a (Employer contributes to Trust Fund)
If your employer contributes to the Trust Fund, you must file a claim for benefits with the Department. You may file this claim in one of two ways:
- You can create an account to apply online through the Department’s Claimant Portal at https://paidleave.mass.gov/login/
- You can call the Department’s call center at (833) 344‑7365 to complete an application over the phone.
Forms and claim instructions are available on the Department’s website at https://www.mass.gov/info-details/documents-needed-to-complete-your-paid-family-and-medical-leave-pfml-application.
- For More Information
For more detailed information, please consult the Department’s website: www.mass.gov/DFML.
You may contact the Department of Family and Medical Leave at:
The Massachusetts Department of Family and Medical Leave
PO Box 838
Lawrence, MA 01842
Contact Center: (833) 344-7365
ACKNOWLEDGMENT
Your signature below acknowledges your receipt of the information above within 30 days from the start date of your employment.
_______________________________________________ __________________
Signature Date
___________________________________________________
Name (Print)