CT PFML provides up to 12 weeks of paid leave (plus 2 additional weeks for pregnancy-related incapacity)

Benefits are 95% of average weekly wage up to the minimum wage threshold, then 60% above it

Job protection is provided for up to 12 weeks under CT FMLA (for employers with 1+ employees)

Employment / FMLAmoderate

Connecticut Paid Family and Medical Leave Application

CT PFML · Connecticut Paid Leave Authority

Application for Paid Family and Medical Leave in Connecticut. Covers medical leave, bonding, caregiving, organ/bone marrow donation, and military qualifying exigencies.

Form Details

Total fields: 34
Auto-fillable: 20 (59%)
Time without BeneFill: 25 minutes
Time with BeneFill: 7 minutes
Time saved: 18 minutes
Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

CT Paid Leave portal (recommended)

https://ctpaidleave.org/s/employee-how-to-apply

Apply online through CT Paid Leave Authority.

Filing Deadline

File within 30 days of the start of leave. You may file up to 30 days in advance for foreseeable leave.

Required Attachments

📎 Medical certification from your healthcare provider
📎 Documentation of qualifying event (bonding, caregiving, military exigency)
📎 Employer information and work history

Processing Time

Approximately 2-3 weeks from receipt of a complete application.

What Happens Next

CT Paid Leave Authority will review and issue a determination. If approved, benefits are 95% of your weekly earnings up to a threshold, then 60% above that threshold.

Tips for This Form

✓ CT PFML provides up to 12 weeks of paid leave (plus 2 additional weeks for pregnancy-related incapacity)
✓ Benefits are 95% of average weekly wage up to the minimum wage threshold, then 60% above it
✓ Job protection is provided for up to 12 weeks under CT FMLA (for employers with 1+ employees)
✓ More info: https://ctpaidleave.org/

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WH-380-E · U.S. Department of Labor

Certification of Health Care Provider for Employee's Serious Health Condition. Medical certification for FMLA leave for the employee's own condition.

FMLA Certification - Family Member's Serious Health Condition

WH-380-F · U.S. Department of Labor

Certification of Health Care Provider for Family Member's Serious Health Condition. Medical certification when employee needs leave to care for a family member.

FMLA Notice of Eligibility and Rights & Responsibilities

WH-381 · U.S. Department of Labor

Notice of Eligibility and Rights & Responsibilities. Employer must provide within 5 business days of FMLA leave request, stating whether employee is eligible.

FMLA Designation Notice

WH-382 · U.S. Department of Labor

Designation Notice. Employer designates leave as FMLA-qualifying or denies it. Must be provided within 5 business days of receiving sufficient certification.

FMLA Certification - Qualifying Exigency (Military)

WH-384 · U.S. Department of Labor

Certification of Qualifying Exigency for Military Family Leave. For leave due to a covered family member's active duty or call to active duty.

FMLA Certification - Serious Injury/Illness of Servicemember

WH-385 · U.S. Department of Labor

Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave (current servicemember).

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Connecticut Paid Leave Authority or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.