FMLA LEAVE REQUEST FORM — WASHINGTON

Table of Contents

1. Employee Information
2. Employer Information
3. Leave Type Requested
4. Federal FMLA Overview
5. Washington Paid Family and Medical Leave (PFML)
6. Leave Schedule and Duration
7. Intermittent or Reduced Schedule Leave
8. Medical Certification
9. Job Restoration Rights
10. Benefits Continuation
11. Washington-Specific Notes
12. Employee Certification and Signature
13. Employer Response

1. Employee Information

2. Employer Information

3. Leave Type Requested

Check all that apply:

Federal FMLA Qualifying Reasons (29 U.S.C. § 2612):
☐ Birth of a child and bonding
☐ Placement of a child for adoption or foster care
☐ Care for spouse, child, or parent with a serious health condition
☐ Employee's own serious health condition
☐ Qualifying exigency arising from military service of a family member
☐ Care for a covered servicemember with a serious injury or illness (Military Caregiver Leave)

Washington PFML Qualifying Reasons (RCW Title 50A):
☐ Family leave — bonding with a new child (birth, adoption, foster placement)
☐ Family leave — care for a family member with a serious health condition
☐ Family leave — qualifying military exigency
☐ Medical leave — employee's own serious health condition
☐ Combined family and medical leave

4. Federal FMLA Overview

The federal Family and Medical Leave Act (29 U.S.C. §§ 2601-2654) provides eligible employees with:

• Up to 12 workweeks of unpaid, job-protected leave in a 12-month period
• Up to 26 workweeks for military caregiver leave in a single 12-month period
• Eligibility: Employed at least 12 months; worked at least 1,250 hours in the 12 months preceding leave; worksite with 50+ employees within 75 miles

5. Washington Paid Family and Medical Leave (PFML)

Under RCW Title 50A, as amended by HB 1213 (effective January 1, 2026):

Benefits Eligibility:
- Employee must have worked at least 820 hours in the qualifying period (the first four of the last five completed calendar quarters)
- No minimum employer size for benefit eligibility — applies to nearly all Washington workers

Benefit Amount:
- Up to 90% of the employee's average weekly wage (lower earners receive higher percentage)
- Maximum weekly benefit: $1,647 (2026)
- Minimum claim duration: 4 consecutive hours of absence for a PFML-covered reason in a week (effective January 1, 2026; reduced from prior 8-hour threshold)

Leave Duration:
- Family leave: Up to 12 weeks in a 52-consecutive-week period
- Medical leave: Up to 12 weeks in a 52-consecutive-week period
- Combined family and medical leave: Up to 16 weeks in a 52-consecutive-week period
- Additional 2 weeks: Available for incapacity due to pregnancy

Premium Rates (2026):
- Total premium: 1.13% of employee wages
- Employer share: 28.57% of total premium
- Employee share: 71.43% of total premium
- Employers with fewer than 50 employees are not required to pay the employer share

6. Leave Schedule and Duration

Type of Leave Schedule:
☐ Continuous leave (one uninterrupted block)
☐ Intermittent leave (see Section 7)
☐ Reduced schedule leave (see Section 7)

PFML Claim Filed with ESD:
☐ Yes — Claim Number: [________________________________]
☐ Not yet — I will file a claim with the Employment Security Department
☐ Not applicable — requesting federal FMLA only (unpaid)

7. Intermittent or Reduced Schedule Leave

Complete only if requesting intermittent or reduced schedule leave.

☐ I understand that intermittent leave for bonding may require employer consent under federal FMLA
☐ My leave is medically necessary on an intermittent basis (certification attached)

8. Medical Certification

Applicable when leave is for a serious health condition.

☐ Medical certification from a health care provider is attached
☐ Medical certification will be submitted within 15 calendar days
☐ Certification will be provided to ESD as part of the PFML claims process
☐ Not applicable — leave is for birth/adoption bonding only

9. Job Restoration Rights

Under Federal FMLA:
- Restoration to the same or an equivalent position with same pay, benefits, and conditions
- Eligibility: 12 months employed, 1,250 hours worked, 50+ employees within 75 miles

Under Washington PFML (effective January 1, 2026 — expanded by HB 1213):
- Job protection phased in based on employer size:
- January 1, 2026 – December 31, 2026: Employers with 25+ employees
- January 1, 2027 – December 31, 2027: Employers with 15+ employees
- January 1, 2028 onward: Employers with 8+ employees
- Employee eligibility for PFML job protection (effective January 1, 2026): Employed for at least 180 days — no minimum hours-worked threshold
- Restoration to the same or equivalent position

☐ I acknowledge my right to job restoration upon timely return from leave
☐ I understand I must return on or before the agreed end date of my leave

10. Benefits Continuation

Under Federal FMLA:
☐ I elect to continue group health insurance coverage during FMLA leave

Under Washington PFML (effective January 1, 2026):
- Employers required to provide PFML job protection must continue healthcare coverage for the full duration of job-restoration-protected leave

☐ I understand I must continue paying my share of health insurance premiums
☐ I understand failure to pay my premium share may result in loss of coverage
☐ I wish to discuss benefit continuation options with HR

11. Washington-Specific Notes

Coordination of Federal FMLA and WA PFML:
- Both laws may apply simultaneously; leave runs concurrently when both are triggered
- WA PFML provides paid benefits; federal FMLA provides unpaid, job-protected leave
- An employee may qualify for WA PFML benefits without qualifying for federal FMLA job protection, or vice versa
- Employers may not require employees to use accrued paid leave concurrently with WA PFML benefits

Key 2026 Changes (HB 1213):
- Expanded job protection to employers with 25+ employees (phasing down to 8+ by 2028)
- Reduced employment tenure requirement for job protection to 180 days (no hours threshold)
- Minimum claim trigger reduced to 4 consecutive hours per week
- Mandatory healthcare continuation during job-protected PFML leave
- Premium rate increased to 1.13%

Filing PFML Claims:
- Employees must file a claim with the Washington Employment Security Department (ESD)
- Claims can be filed online at paidleave.wa.gov
- Benefits are paid by the state, not by the employer (unless employer has an approved voluntary plan)

Voluntary Plans:
- Employers may apply for approval of a voluntary plan that provides benefits at least equivalent to the state plan
- Employees of voluntary-plan employers file claims directly with their employer

Anti-Retaliation:
- Employers may not discriminate or retaliate against employees for requesting or using PFML leave

12. Employee Certification and Signature

I certify that the information provided in this request is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of leave, disciplinary action, or termination. I have read and understand the leave rights described in this form under both federal FMLA and the Washington Paid Family and Medical Leave program.

13. Employer Response

To be completed by employer within five (5) business days of receiving this request.

☐ Leave request APPROVED under federal FMLA
☐ Leave request APPROVED under Washington PFML
☐ Leave request APPROVED under both federal FMLA and WA PFML (concurrent)
☐ Leave request DENIED — reason: [________________________________]
☐ Additional information or certification required: [________________________________]

This form is provided as a template by ezel.ai and does not constitute legal advice. Washington employers should consult with qualified employment law counsel regarding compliance with RCW Title 50A (Washington PFML), HB 1213 (2025 amendments), and 29 U.S.C. §§ 2601-2654 (federal FMLA).