Njfli form 2010-2019-2026

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The document is an application form for Family Leave Insurance Benefits (FL-1) from the New Jersey Division of Temporary Disability Insurance. It outlines the rules for filing a claim, including responsibilities, deadlines, and appeal rights. The form allows individuals to apply for benefits while caring for a seriously ill family member or bonding with a newborn or newly adopted child. It includes detailed instructions on completing the application, necessary certifications, and information required from both the claimant and their employer.

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Begin with Part A. Fill in your full name, address, and Social Security Number clearly. Ensure all information is legible to avoid processing delays.
Indicate the reason for your family leave by selecting either 'Care of Family Member' or 'Bond With Child'. If applicable, complete Part B for bonding claims or Part C for caregiving claims.
If claiming intermittent leave, complete Part E by listing the dates you were absent from work. Make sure to include your name and Social Security Number on this schedule.
Review all sections carefully before signing. Ensure that you have included any necessary attachments and that your employer has completed Part D if required.
Submit the completed form by mailing or faxing it to the Division of Temporary Disability Insurance as instructed on the form.

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