Business Information

Tell us about your business

UBI (uniform business identifier)

Legal Entity Name

Address Line 1

Address Line 2

Address Line 3

City

State

Zip

Start Your Plan

Contact Information

If we have questions about your voluntary plan application, whom should we contact? Please provide contact information below.

First Name

Last Name

Email Address

Phone Number

Voluntary Plan Details

What kind of paid leave plan will you offer? *

Type of Plan

Will all of your Washington employees, including full-time, part-time, permanent or temporary employees, who work at least 820 hours in a qualifying period, with at least 340 of those hours in your employment, be eligible for benefits under your plan? *

What is the minimum duration of paid weeks your plan makes available to employees during a period of 52 consecutive calendar weeks? *

What is the minimum duration of paid weeks your plan makes available to employees for combined paid family and medical leave during a period of 52 consecutive calendar weeks?

How many paid weeks will your plan allow paid medical leave to be extended if an employee experiences complications from pregnancy which results in incapacity? *

About Your Plan

Providing Care

Note: A serious health condition is an illness, injury, impairment, or physical or mental condition that involves inpatient care in a hospital, hospice, or residential medical care facility, or continuing treatment by a health care provider.

Will your plan provide employees paid leave if they are unable to work due to a serious health condition? *

Will your plan provide employees paid leave to provide care, including physical or psychological, to a family member with a serious health condition? *

Will your plan provide employees paid leave to care for a child, grandchild, grandparent, parent, or sibling with a serious health condition? *

Will your plan allow employees paid leave to care for their husband or wife, or state registered domestic partner with a serious health condition? *

Will your plan allow employees paid leave to care for a child with a serious health condition whether biological, adopted, foster, step, or a child of whom the employee has legal guardianship over regardless of age or dependency status?

Will your plan provide employees paid leave to bond with a child during the first 12 months after the child's birth, or the first 12 months after placement of a child under the age of 18?

If an employee's spouse, child, or parent is a current member of the Armed Forces (including the National Guard and Reserves) and is on covered active duty or notified of an impending call or ordered to covered active duty, will the employee be eligible for paid family leave under your plan?

Leave and Benefits

Will your plan pay benefits that are greater than or equal to the state's plan to your eligible employees? *
For information about benefit calculation please visit the Voluntary Plan guide.

Premium Deductions

Do you intend to withhold premiums from your employees' wages? *
For information about premium calculation please visit the Premium Calculator page.

Job Protection

Do you have 50 or more employees? *

Will you protect job of an employee on leave who was employed with your business at least 9 months and 965 hours in a 12-month period before the leave began? *

Health Benefits

Do you currently provide employees with health benefits? *

Will you continue to provide the same health benefits while the employee is on leave as long as they can maintain their share of the employee's cost of medical premiums? *

Acknowledgment

I certify, by my submission of this request, this plan affords current and future Washington employees employed under this Unified Business Identifier (UBI) leave and benefits that are greater than or equal to that of what the state plan offers. I acknowledge this plan will remain in effect for no less than one year from the initial start date and continuously thereafter unless withdrawn or the plan is terminated by the department for failure to comply. In the event my plan is withdrawn or terminated, I agree to remit all moneys collected and owed, including any interest accrued, to the department. I understand this plan must be approved annually for the first three years with any subsequent approval required for any changes made to the plan not mandated by law.

I have read and accept the laws and rules set forth in RCW 50A.05 and understand I am subject to employer penalties for any violations of this chapter.

Carefully review your voluntary plan application before continuing. Once you move on to uploading your supporting documents, you will not able to make adjustments or corrections to your application.

Upload Documents

In addition to your application, our team will review your voluntary plan policy. Please upload below.

To upload a file, select the file from your computer and click 'Upload'. Once the file is uploaded, you will not be able to modify or delete this file.

Multiple files may be uploaded at the same time by multi-selecting using the Shift key.

File formats allowed: .pdf, .doc, .docx, .xls, .xlsx, .tif, .tiff, .jpeg, .jpg, .png
Maximum file size allowed 5 MB

Voluntary Plan Policy

Files were selected for upload. You must submit the form to save your changes.

Comments (Optional)

By clicking "Submit" you're confirming that your application is complete and ready for review and determination.

Note: Please don't click submit more than once. Doing so creates multiple invoices for your voluntary plan fee.