Paid Family & Medical Leave Certification Form

Page 1 of 5 Fs/f PFML-CERT-FORM (12/21) Paid Family & Medical Leave Certification Form Metropolitan Life Insurance Company Things to Know Before You Begin • Please complete Sections 1 before giving this form to the medical provider. • To ensure benefit payments and/or (where applicable) job protection, MetLife requires that you submit a timely and complete certification based on your leave reason. • Remember to add your First and Last Name along with the claim form number to all pages so that we can match this certification with your absence request. Reminder: Forms marked as lifetime, unknown, as needed, indeterminate or the like, may be returned as incomplete. SECTION 1: Employee Information Employee - First Name Middle Name Last Name Claim Number Employer Name Dates of Leave: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Continuous Intermittent Reason for Leave My own serious health condition (including disability) ICD-10 Diagnosis Code To bond with a child Military Exigency Safe Leave (CT only) Organ/Bone Marrow Donor To care for a family member due to a serious health condition Qualified Leave reason may vary by state 1. Relationship to Employee: (approved family member may vary by state and FMLA program) Self Parent in law Grandchild Child (under 18) Spouse Sibling Child (over 18) Domestic Partner Other Parent Grandparent Description if Other 2. For CT and MA: If care of Family member, did the Illness or Injury incur in the line of military duty? Yes No Authorization and Signatures By signing below, I certify that the intent of the information in this document is to support my need to be absent from work due to the qualifying reason checked above. Signature Date (mm/dd/yyyy)