Page 2 of 4 Fs/f MET-PFML (11/21) Name of Employee Requesting PFML First Name Middle Name Last Name Employee ID 14. If providing less than 30 days advance notice from the estimated PFML start date, please explain. SECTION 2: Employment Information (To be completed by Employee) 15. Business Name 16. Date of Hire (mm/dd/yyyy) 17. Phone Number 18. Work Location - Street Address City State ZIP 19. Are you still actively at work? Yes No Termination Date (mm/dd/yyyy) 20. Average Quarterly Wage (This data will be requested of both employee and employer) 21. Scheduled Work Week: M Tu W Th F Sa Su 22. Is your schedule: Regular Variable ? 23. Will you receive company paid leave or benefits during the leave? Yes No If yes, list 24: Are you currently receiving Unemployment? Yes No 25. Are you currently receiving Workers' Compensation Benefits? Yes No Disclosure Statement: Information regarding PFML benefits received by the employee, such as payments received and types of leave, will be provided to the employer. SECTION 3: Declaration and Signature Any person who files an application for leave or benefits containing any materially false information, or conceals information for the purpose of misleading MetLife concerning any material fact may be subject to penalties. I am hereby making a request for paid family and medical leave benefits under applicable state law. My signature affirms that the information I am providing is true and accurate to the best of my knowledge and belief. Signature of Employee Date (mm/dd/yyyy)