FAMILY AND MEDICAL LEAVE REQUEST FORM

State of Colorado

Federal Authority: 29 U.S.C. §§ 2601 et seq.; 29 C.F.R. Part 825
State Authority: Colorado Family and Medical Leave Insurance (FAMLI) Act, C.R.S. §§ 8-13.3-501 et seq.

TABLE OF CONTENTS

1. Employee Information
2. Employer Information
3. Type of Leave Requested
4. Federal FMLA Overview
5. Colorado FAMLI Act Provisions
6. Leave Schedule and Dates
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits Continuation
11. Colorado-Specific Notes
12. Employee Acknowledgment and Signature
13. Employer Response

1. EMPLOYEE INFORMATION

2. EMPLOYER INFORMATION

3. TYPE OF LEAVE REQUESTED

Please indicate the reason for your leave request:

☐ Own Serious Health Condition — A serious health condition that renders the employee unable to perform essential job functions (29 U.S.C. § 2612(a)(1)(D); C.R.S. § 8-13.3-503)

☐ Family Member Care — To care for a family member with a serious health condition (29 U.S.C. § 2612(a)(1)(C); C.R.S. § 8-13.3-503)
- Relationship to employee: [________________________________]
- Name of family member: [________________________________]

☐ Birth and Bonding — For the birth of a child and to bond with the newborn (29 U.S.C. § 2612(a)(1)(A); C.R.S. § 8-13.3-503)

☐ Adoption or Foster Care Placement — For placement of a child for adoption or foster care (29 U.S.C. § 2612(a)(1)(B); C.R.S. § 8-13.3-503)

☐ Qualifying Exigency — For a qualifying exigency related to a family member's military service (29 U.S.C. § 2612(a)(1)(E))
- Type of exigency: [________________________________]

☐ Military Caregiver Leave — To care for a covered servicemember with a serious injury or illness (29 U.S.C. § 2612(a)(3))
- Relationship to servicemember: [________________________________]

☐ Safe Leave (Domestic Violence / Sexual Assault) — For needs arising from domestic violence, stalking, or sexual assault under Colorado law (C.R.S. § 8-13.3-503(1)(b)(IV))

4. FEDERAL FMLA OVERVIEW

• Eligibility: Employee must have worked for the employer for at least 12 months, with at least 1,250 hours of service during the preceding 12 months, at a worksite with 50+ employees within 75 miles (29 C.F.R. § 825.110).
• Leave Entitlement: Up to 12 workweeks of unpaid, job-protected leave in a 12-month period.
• Military Caregiver Leave: Up to 26 workweeks in a single 12-month period (29 U.S.C. § 2612(a)(3)).
• Notice Requirement: At least 30 days' advance notice when foreseeable; as soon as practicable when not foreseeable.

5. COLORADO FAMLI ACT PROVISIONS

5A. FAMLI Eligibility

• No employer-size threshold. FAMLI applies to all employers in Colorado (employers with fewer than 10 employees are exempt from paying the employer share of premiums but employees are still covered).
• Employee Eligibility: Must have earned at least $2,500 in wages in Colorado during the base period.
• Self-employed individuals may opt into FAMLI coverage.

5B. FAMLI Leave Duration

• Up to 12 weeks of paid FAMLI leave per benefit year.
• Additional 4 weeks for employees with a serious health condition related to pregnancy or childbirth complications (up to 16 weeks total).
• Additional 12 weeks (effective January 1, 2026, per SB 25-144) for a parent with a child receiving neonatal intensive care unit (NICU) treatment (up to 24 weeks total in qualifying cases).

5C. FAMLI Wage Replacement

5D. FAMLI Premiums (2026)

• Total Premium Rate: 0.88% of wages (reduced from 0.9% per SB 25-144, effective January 1, 2026).
• Split: Employer pays 0.44%; employee pays 0.44% (employers with fewer than 10 employees pay 0%).
• Employers may elect to pay all or a greater share of the employee premium.

5E. FAMLI Family Member Definition

FAMLI defines "family member" more broadly than federal FMLA:
- Spouse, domestic partner, child (of any age), parent, sibling, grandparent, grandchild, or any individual with whom the employee has a significant personal bond that is or is like a family relationship.

☐ Employee is requesting FAMLI paid benefits in addition to FMLA job protection.
☐ Employee is requesting FMLA only (not FAMLI).

FAMLI Claim Number (if filed): [________________________________]

6. LEAVE SCHEDULE AND DATES

Employer's 12-Month Leave Period Method (FMLA): [________________________________]

FMLA Leave Already Used This Period: [____] weeks [____] days

FMLA Leave Remaining: [____] weeks [____] days

FAMLI Leave Already Used This Benefit Year: [____] weeks [____] days

FAMLI Leave Remaining: [____] weeks [____] days

7. INTERMITTENT OR REDUCED SCHEDULE LEAVE

☐ I am not requesting intermittent or reduced schedule leave.

☐ I am requesting intermittent or reduced schedule leave.

If intermittent or reduced schedule leave is requested:

8. MEDICAL CERTIFICATION

☐ Medical certification is attached (DOL Form: [________________________________])

☐ Medical certification will be provided by: [__/__/____]

☐ Medical certification is not required for this leave type

Certification Form Required:
- ☐ WH-380-E — Employee's Serious Health Condition
- ☐ WH-380-F — Family Member's Serious Health Condition
- ☐ WH-384 — Qualifying Exigency for Military Family Leave
- ☐ WH-385 — Serious Injury or Illness of a Current Servicemember
- ☐ WH-385-V — Serious Injury or Illness of a Veteran
- ☐ FAMLI Division certification form (for FAMLI claims)

9. JOB RESTORATION RIGHTS

• Federal FMLA: Restoration to the same or equivalent position (29 U.S.C. § 2614(a)).
• Colorado FAMLI: Job protection is provided to all FAMLI-eligible employees, regardless of employer size. Employers may not retaliate against employees for requesting or taking FAMLI leave (C.R.S. § 8-13.3-509).

☐ Employee is designated as a "key employee" under 29 U.S.C. § 2614(b).

10. BENEFITS CONTINUATION

• Federal FMLA: Employer must maintain group health insurance during leave (29 U.S.C. § 2614(c)).
• Colorado FAMLI: Employer must maintain any healthcare benefits the employee had prior to taking leave for the duration of the leave. The employee must continue to pay their share of the cost of benefits (C.R.S. § 8-13.3-510).

11. COLORADO-SPECIFIC NOTES

• Concurrent Leave: Where an employee qualifies for both FMLA and FAMLI, the leave runs concurrently. FAMLI provides wage replacement; FMLA provides job protection for employees at larger employers.
• FAMLI Division: Claims for FAMLI benefits are filed with the Colorado FAMLI Division at famli.colorado.gov.
• Private Plan Option: Employers may use an approved private plan in lieu of the state FAMLI program if the plan meets or exceeds FAMLI benefits.
• No Waiting Period for FAMLI Benefits: Benefits are payable starting the first day of leave (no waiting week).
• Employer Cannot Require PTO Substitution: Under FAMLI, an employer may not require an employee to use accrued paid leave before or instead of FAMLI benefits; the employee may choose to do so voluntarily.

☐ Employer participates in the state FAMLI program.
☐ Employer has an approved private FAMLI plan.

12. EMPLOYEE ACKNOWLEDGMENT AND SIGNATURE

By signing below, I certify that:

1. The information provided is true and complete to the best of my knowledge.
2. I understand my rights under federal FMLA and the Colorado FAMLI Act.
3. I understand that medical certification may be required.
4. I understand that misrepresentation may result in disciplinary action and/or denial of benefits.

13. EMPLOYER RESPONSE

☐ APPROVED — Leave is designated as FMLA-qualifying and/or FAMLI-qualifying.
☐ PENDING — Additional information or certification required.
☐ DENIED — Leave is not qualifying. Reason: [________________________________]

Notices Provided:
- ☐ WH-381 (Eligibility/Rights & Responsibilities Notice) — Date: [__/__/____]
- ☐ WH-382 (Designation Notice) — Date: [__/__/____]
- ☐ FAMLI Rights Notice — Date: [__/__/____]

This form does not replace U.S. Department of Labor FMLA forms or Colorado FAMLI Division claim forms. Employers must issue all required federal and state notices.

Sources and References:
- U.S. Department of Labor — FMLA
- Colorado FAMLI Division
- C.R.S. §§ 8-13.3-501 et seq.
- SB 25-144 (2026 FAMLI Amendments)
- FAMLI Employer FAQs