Request for Paid Family & Medical Leave

Page 1 of 4 Fs/f MET-PFML (11/21) Request for Paid Family & Medical Leave (MET-PFML) - Part A Metropolitan Life Insurance Company SECTION 1: Employee Information (To be completed by Employee) 1. Legal First Name Legal Middle Name Legal Last Name 2. Other Last Names, if Any, Under Which Employee Has Worked 3. Mailing Address City State ZIP Country (if not U.S.A.) 4. Social Security Number Employee ID 5. Date of Birth (mm/dd/yyyy) 6. Primary Phone Number 7. Email 8. Gender Male Female Not Designated/Other 9. Preferred Language if Other Than English Other Paid Family and Medical Leave (PFL or PML) Request 10. a. Reason for Leave: My Own Serious Health Condition (including disability) Bond With Child Safe Leave Care for Family Member Military Qualifying Event • If care of Family member, did the Illness or Injury incurred in the line of military duty? Yes No b. 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 11. Dates of Leave: Starting (mm/dd/yyyy) To (mm/dd/yyyy) Please complete the PFML Certification to support the qualifying leave reason. 12. Will the leave include a reduced leave schedule or intermittent leaves? Yes No 13. Notice a. Did you provide notice to your employer? Yes No b. If so, when and to whom?