The Connecticut Paid Leave Employment Verification Form is the document Aflac sends you after one of your employees files a paid leave claim, and you have 10 calendar days from receipt to return it completed.1CT Paid Leave Authority. Employment Verification Form: Job Aid What you put on it determines whether your employee qualifies and how much they are paid each week, so accuracy matters more than speed.
Who Has to Complete the Form
Every paid leave claim generates a verification form, and completing it is not optional. If your employee works for more than one participating employer, each employer fills out a separate form. Former employers are included too: if the person left your company but files for paid leave within 12 weeks of their last day, the form still comes to you.1CT Paid Leave Authority. Employment Verification Form: Job Aid
Two groups are exempt. Federal government employers and non-contributing municipalities do not participate in the program and will not receive the form. Employers running an approved private paid leave plan under C.G.S. § 31-49o for the entire duration of the requested leave are also exempt.1CT Paid Leave Authority. Employment Verification Form: Job Aid Everyone else responds.
One point of confusion worth clearing up: the form does not live inside the CT Paid Leave employer portal. It arrives separately from Aflac and goes back directly to Aflac.2CT Paid Leave Authority. Contact Us and Frequently Asked Questions You also need to download the PDF before entering any data; it is not fillable in the browser.1CT Paid Leave Authority. Employment Verification Form: Job Aid
What to Gather Before You Open the Form
Pull these records first. Hunting for payroll data mid-form burns time against the 10-day clock.
- Employee identification: full name, date of birth, last four digits of the Social Security number, and the case number from the claim notification.
- Employment dates: hire date and, if applicable, separation date.
- Pay rate and schedule: current rate of pay, typical workdays, and standard weekly hours. For employees whose schedules vary, you need hours worked in each of the 12 weeks before you received the form or before leave began, whichever came first, including overtime and any hours covered by paid time off.
- Scheduled closures: dates of company holidays, shutdowns, or other closures during which the employee would not normally work.
- Other income sources: whether the employee has applied for or been approved for workers’ compensation, plus details on any employer-provided income-replacement benefits such as short-term disability, including whether those benefits are primary or secondary and what percentage of wages they cover.
Report information as of the date you received the form or the first date of leave, whichever is earlier.1CT Paid Leave Authority. Employment Verification Form: Job Aid
Filling Out the Six Sections
Section 1: Applicant’s Leave Information
Enter the employee’s first name, last name, date of birth, and last four digits of their SSN. Add the beginning and expected end dates of leave, the case number, and the leave schedule type: continuous, intermittent, or reduced. Select the reason for leave from the options provided: the employee’s own serious health condition, caregiver leave, bonding leave, military caregiver leave, qualifying exigency leave, or family violence leave.3Barnes Group Benefits. Connecticut Paid Leave – Employment Verification
Section 2: Employer Information
Provide your company name, address, Federal Employer Identification Number, and a contact person’s name, phone number, and email. If your organization falls into one of the exempt categories listed on the form (federal government, railroad, private elementary or secondary school, sovereign nation, government of another state, or a non-contributing municipality or state government employee), check the applicable box.3Barnes Group Benefits. Connecticut Paid Leave – Employment Verification
Section 3: Income and Work Schedule
This section drives the benefit calculation. Enter the rate of pay, hire date, and separation date if applicable. List the days the employee typically works and standard hours per week. For variable schedules, enter hours worked in each of the 12 weeks before you received the form or before leave began, whichever is earlier. Include actual overtime hours plus any PTO hours covered during those weeks.3Barnes Group Benefits. Connecticut Paid Leave – Employment Verification
Section 4: Scheduled Closures
List company holidays, planned shutdowns, or other scheduled closures during which the employee would not ordinarily work. The Authority uses this to avoid counting closure days as leave days, which would reduce the employee’s available leave balance incorrectly.
Section 5: Other Potential Sources of Income
Answer whether the employee has applied for or been approved for workers’ compensation, and include the approved dates. Then report any employer-provided income-replacement benefits such as short-term disability. If your company provides them, specify whether the employee will receive full wages, partial wages, or nothing, and whether those payments are primary (paid first, with CT Paid Leave supplementing) or secondary (paid after CT Paid Leave is calculated).3Barnes Group Benefits. Connecticut Paid Leave – Employment Verification Mislabeling primary versus secondary is one of the fastest ways to cause a payment error or delay, because it changes how much the state fund pays.
Section 6: Leave Requiring Additional Employer Approval
If the employee is requesting intermittent or reduced-schedule leave to bond with a newborn, newly adopted child, or newly placed foster child, this section asks whether you have approved the arrangement and asks you to describe the expected timing, frequency, and duration. Intermittent bonding leave requires employer consent under Connecticut law, unlike intermittent leave for the employee’s own serious health condition.
Submitting the Completed Form
Return the completed form to Aflac within 10 calendar days of receiving it.3Barnes Group Benefits. Connecticut Paid Leave – Employment Verification The Authority confirms that timely submission is the employer’s obligation and that delays can hold up the employee’s benefit payments.2CT Paid Leave Authority. Contact Us and Frequently Asked Questions Save or print a copy for your own records before sending it back. If Aflac has questions, they will follow up using the contact information you entered in Section 2.
Why Section 3 and Section 5 Accuracy Matters
The Authority calculates benefits using the employee’s “base period” earnings, which is the first four of the last five completed calendar quarters.4Connecticut Paid Leave. Glossary of Terms The hours and pay data you report feed into the average weekly wage used to set the benefit.
The income reported in Section 5 can reduce what the employee receives from the state fund. When an employer short-term disability plan is designated as primary, CT Paid Leave pays the difference up to the benefit cap. When it is secondary, the state pays first and the employer plan tops off the difference. Reporting these benefits inaccurately can trigger overpayments that the Authority later recovers from the employee.
Penalties for False Information
Providing false information on the Employment Verification Form carries real consequences. Under C.G.S. § 31-49r, an employer who intentionally helps facilitate a fraudulent claim faces the same financial penalty as the claimant: repayment of benefits plus a penalty equal to 50 percent of the benefits paid through misrepresentation. Individuals who willfully misrepresent material facts are disqualified from the program for two years. Unpaid penalties accrue interest at 1 percent per month, and the Authority can refer the debt to the Commissioner of Administrative Services for collection.5Justia Law. Connecticut Code 31-49r – Disqualification From Program
Connecticut employers must maintain accurate employment records for at least three years.6Connecticut eRegulations. Sec. 31-62-E14 Records Keep a copy of every completed verification form with the payroll data behind it. If the Authority audits your submission or an employee disputes a determination, those records are your defense.
The Form Does Not Replace FMLA Certification
If your company employs 50 or more people within 75 miles, the CT Paid Leave claim likely runs concurrently with federal Family and Medical Leave Act protections. The Employment Verification Form is not a substitute for the separate FMLA medical certification you are entitled to request. The FMLA certification requires clinical details the CT Paid Leave form does not collect, including the health care provider’s contact information, the condition’s start date and expected duration, relevant medical facts, and a statement about the employee’s inability to perform essential job functions.7U.S. Department of Labor. Medical Certification Under the Family and Medical Leave Act Sending both to the employee at the same time saves a round of back-and-forth.