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I need to care for a family member experiencing a serious health condition

You are caring for a family member who is receiving treatment for or recovering from a serious health condition or is recovering from childbirth. A family member means:

• your spouse
• your child (of any age)
• your parent or spouse's parent
• your grandparent or spouse’s grandparent 
• your grandchild (of any age)
• sibling or spouse's sibling or sibling's spouse
• an individual related to you by blood or affinity whose close association with you is the equivalent to one of the listed family relationships
  
  

Statement of Family Relationship

• The Statement of Family Relationship is included in your Notice of Application and has the case number and name pre-filled.
• You must complete a CT Paid Leave Statement of Family Relationship.

Sample Forms

Certification for Care of A Family Member with a Serious Health Condition

The Certification for Care of A Family Member with a Serious Health Condition is included in your Notice of Application and has the case number and name pre-filled.

• Complete the "Applicant Information", "Who is the Paid Leave for?", "Family Member's Information", and "Family Member's Health Care Provider Information" sections at the top of the form.
• Then, provide this form to your family member's healthcare provider to complete the remaining sections of the form.
• Your family member's healthcare provider may return the form directly to Aflac, or they may return it to you to upload through the CT Paid Leave Aflac portal. This form must be returned to Aflac within 15 days.
• Your family member's healthcare provider cannot charge a fee to fill out this form under Connecticut Law C.G.S. 31-49r(e).
  
  • Date of illness or incapacity must have an actual start and end date. These dates can be estimated and updated later. Entering "To be determined" or "Unknown" will result in the application being denied.
  • Follow up with your family member's healthcare provider to ensure that the Certification for Care of A Family Member with a Serious Health Condition has been completed and returned to Aflac.
  • We will accept fully completed FLMA medical documentation as an alternative to the Certification for Care of A Family Member with a Serious Health Condition.

  If you are having trouble getting your family member's healthcare provider to complete and return the forms, call Aflac (877-499-8606) for guidance.

Sample Forms

I have been impacted by family violence

If you are experiencing family violence, you may be eligible to receive up to 12 days of CT Paid Leave benefits to seek medical or psychological care, to seek support from a victim services organization, to relocate, or to participate in any civil or criminal proceeding relating to family violence.

Family Violence Statement

• The Family Violence Statement is included in your Notice of Application and has the case number and name pre-filled.
• You must complete a CT Paid Leave Family Violence Statement and submit appropriate supporting documentation as listed in the Family Violence Statement.

Supporting documentation, provide copies of:

• Appointments
• Court dates
• Other proof of services received

Sample Forms

I need to take military family leave

Military family leave can be taken for military caregiver leave or for qualifying exigency leave.

You are caring for family member who is a Current Service Member and who is experiencing a serious illness or injury incurred in the line of duty on active duty.

Certification for Serious Injury or Illness of a Current Service Member for Military Caregiver Leave

• The Certification for Serious Injury or Illness of a Current Service Member for Military Caregiver Leave is included in your Notice of Application and has the case number and name pre-filled.
• You and the healthcare provider of your military family member must complete this form.
• We will accept one of the following as an alternative to Certification for Serious Injury or Illness of a Current Service Member for Military Caregiver Leave:
  • Fully completed FLMA medical documentation (Form WH-385)
  • Copy of an ITA (Invitational Travel Authorization)
  • Copy of an ITO (Invitational Travel Order)

Sample Forms

I am experiencing a serious health condition

Your leave reason is either your own injury or illness, organ donation or bone marrow donation.

Certification for Serious Health Condition

The Certification for Serious Health Condition is included in your Notice of Application and has the case number and name pre-filled.

• Complete the "Applicant Information", "Employer Information" and "What is the Paid Leave for?" sections at the top of the form.
• Then, provide this form to your healthcare provider to complete the remaining sections of the form.
• Your healthcare provider may return the form directly to Aflac, or they may return it to you to upload through the CT Paid Leave Aflac portal. This form must be returned to Aflac within 15 days.
• Your healthcare provider cannot charge a fee to fill out this form under Connecticut law, C.G.S. 31-49r(e)
• Date of illness or incapacity must have an actual start and end date. These dates can be estimated and updated later. Entering "To be determined" or "Unknown" is likely to cause the application to be delayed or denied.
• Follow up with your healthcare provider to ensure that the Certification for Serious Health Condition has been completed and returned to Aflac.
• We will accept fully completed FLMA medical documentation as an alternative to the CT Paid Leave Medical Certification.

If you are having trouble getting your healthcare provider to complete and return the forms, call Aflac (877-499-8606) for guidance

I need to take military family leave

Military family leave can be taken for military caregiver leave or for qualifying exigency leave.

You are addressing specific circumstances associated with the deployment of a parent, spouse, or child to covered military duty.

Certification for Military Leave for Qualifying Exigency

• The Certification for Military Leave for Qualifying Exigency is included in your Notice of Application and has the case number and name pre-filled.
• You must complete a Certification for Military Leave for Qualifying Exigency form and submit appropriate supporting documentation as listed in the form.

Supporting documentation

• Copy of orders or letter of impending activation from the family member's officer; or
• Copy of documentation validating the specific activity for which you are taking leave.

Sample Forms

Your leave reason is pregnancy/childbirth

This leave is taken by the pregnant parent during their pregnancy or to recover from the delivery.

Certification for Serious Health Condition

The Certification for Serious Health Condition is included in your Notice of Application and has the case number and name pre-filled.

• Complete the "Applicant Information", "Employer Information" and "What is the Paid Leave for?" sections at the top of the form.
• Then, provide this form to your healthcare provider to complete the remaining sections of the form.
• Your healthcare provider may return the form directly to Aflac, or they may return it to you to upload through the CT Paid Leave Aflac portal. This form must be returned to Aflac within 15 days.
• Your healthcare provider cannot charge a fee to fill out this form under Connecticut law, C.G.S. 31-49r(e)
• Date of illness or incapacity must have an actual start and end date. These dates can be estimated and updated later. Entering "To be determined" or "Unknown" will result in the application being denied.
• Follow up with your healthcare provider to ensure that the Certification for Serious Health Condition has been completed and returned to Aflac.
• We will accept fully completed FLMA medical documentation as an alternative to the CT Paid Leave Medical Certification.

If you are having trouble getting your healthcare provider to complete and return the forms, call Aflac (877-499-8606) for guidance.

Sample Forms

Your leave reason is adoption or foster care placement/bonding

This leave is taken by a worker to attend to activities needed to process the child's adoption or foster care placement and/or to bond with the child after the adoption or placement.

Bonding Statement

• The Bonding Statement is included in your Notice of Application and has the case number and name pre-filled.
• You must complete a CT Paid Leave Bonding Statement and submit appropriate supporting documentation as listed in the Bonding Statement.

Supporting documentation depends upon the type of bonding:

• Adopted child
  • Copy of adoption papers or court documents that includes child's date of birth and adoption date.
• Foster child
  • Copy of child's foster care papers or a court document that includes child's date of birth and date(s) of placement.

Sample Forms

Your leave reason is childbirth bonding.

This leave is taken by a worker to bond after the birth of their child. Bonding leave can be taken by both parents.

Bonding Statement

• The Bonding Statement is included in your Notice of Application and has the case number and name pre-filled.
• You must complete a CT Paid Leave Bonding Statement and submit appropriate supporting documentation as listed in the Bonding Statement.

Supporting documentation for a biological child:

• CT Paid Leave Certification of Birth; or
• Copy of Hospital Discharge document (accepted only if it includes the name of the applicant); or
• Copy of the child's Birth Certificate

Sample Forms

Employment Verification Form

The Employment Verification Form is included in your Notice of Application and has the case number and name pre-filled.

1. Provide this form to your employer.
2. Your employer must complete and return the form to Aflac within 10 days.
3. Your employer may return the form directly to Aflac, or they may return it to you to upload through the CT Paid Leave Aflac portal.
4. Follow up with your employer to ensure that the Employment Verification Form has been completed and returned to Aflac.
5. If your employer has questions, they may use the Employment Verification Form Job Aid or contact us.

Sample Forms

Sole Proprietor/Self-Employed Employment Verification Form

The Sole Proprietor/Self Employed Employment Verification form is included in your Notice of Application and has the case number and name pre-filled.

• You must complete and return the form to Aflac within 10 days.
• For additional assistance, view our Sole Prop/Self Employed Employment Verification Form Job Aid or contact us.

Sample Forms