Paid Leave Oregon Intermittent leave Weekly Claim Form Instructions

Paid Leave Oregon Intermittent leave Weekly Claim Form

Product Information

The Weekly Claim Form is used for filing an intermittent leave claim. An intermittent leave claim refers to leave taken periodically in separate blocks of time or when leave is taken for two or more leave types simultaneously for an entire work day or work week from all employment. This form is specifically designed for use with the Paid Leave Oregon program. To receive payment on an intermittent leave claim, it is important to file a weekly claim within the first 30 days from the end of the week in which the intermittent leave was taken. Failure to file the weekly claim within this timeframe will result in the inability to receive payment for the leave. If you have requested retroactive intermittent leave and are still waiting for approval, this form should be filed along with your Paid Leave Oregon Application for Benefits or Claim Amendment Form. The quickest and easiest way to file a weekly claim, check the status of your claim, and view your benefit payments is by creating a Paid Leave Oregon account on the official website: frances.oregon.gov. Consecutive leave claims, which refer to leave taken for a continuous period of time without interruption, are not applicable to this form. If your consecutive leave claim is approved, your payments will be automatically sent to you. This form is only intended for intermittent leave claims.

Product Usage Instructions

1. Report the days of leave taken for each employer separately, including any self-employment if you choose coverage. This form can be used for up to three employers. If you have more than three employers, submit this form as many times as needed for the week to cover all of your employers.

2. If you have started any new jobs or left any jobs since your last claimed week of benefits, file a Claim Amendment Form in addition to the Weekly Claim Form.

3. Provide the following information for each employer:

   • Employer business name: Enter the name of your employer or self-employed business if you choose coverage.
   • Employer type: Check “Regular” if your employer participates in the statewide Paid Leave Oregon plan. Check “Equivalent plan” if your employer participates in their own equivalent plan.
   • Other benefits coverage: Check “Yes” if you are eligible for Unemployment Insurance or Workers’ Compensation benefits during the week. Otherwise, check “No”.

4. Enter the dates for the week. A week for Paid Leave Oregon runs from Sunday through Saturday. Do not claim multiple weeks on this form.

5. For each day of the week, indicate your work status by
   selecting one of the following:

   • “Took paid leave” – If you took paid leave on a day you would normally work.
   • “Worked” – If you worked for this employer at all on this day.
   • “Did not work” – If you did not work for this employer at all on this day.

6. If you took paid leave on any day, specify the leave type for each day. You can choose from the following options: Family-Care, Family-Bonding, Medical, Safe, or Pregnancy.

For example, if you took medical leave from ABC Corporation on Sunday through Wednesday, did not work any of the days, and were not eligible for Unemployment Insurance or Workers’ Compensation benefits, fill out the form accordingly.

General Instructions

• Complete this form if you have an intermittent leave claim. An intermittent leave claim is defined as leave taken periodically in separate blocks of time or when leave is taken for two or more leave types simultaneously for an entire work day or work week from all employment.
• To receive payment on an intermittent leave claim, you must file a weekly claim within the first 30 days from the end of the week that you took intermittent leave. If you file your weekly claim later than 30 days from the end of the week the leave happened, you can no longer receive payment for it.
• File this form with your Paid Leave Oregon Application for Benefits or Claim Amendment Form if you requested retroactive intermittent leave and are still waiting for approval of your benefits application or of the claim amendment.
• The fastest and easiest way to file a weekly claim, see the status of your claim, and see your benefit payments is by creating a Paid Leave Oregon account at frances.oregon.gov.
• Don’t use this form if you are taking consecutive leave. If your consecutive leave claim is approved, your payments will be sent to you automatically. A consecutive leave claim is defined as leave taken for a continuous period of time, without interruption, based upon a claimant’s regular work schedule from all employment for a single qualifying purpose.

Form Instructions

Report the days of leave taken for each employer (including any self- employment, if chose coverage) separately. This form can be used for up to three employers. If you have more than three employers, submit this form as many times as is needed for the week to cover all of your employers.
Note : If you have started any new jobs or left any jobs since you last claimed a week of benefits you will also need to file a Claim Amendment Form.

• Employer business name : Enter the name of your employer or self-employed business if you chose coverage.
• Employer type: For each employer, check “regular” if your employer participates in the statewide Paid Leave Oregon plan or check “Equivalent plan” if your employer participates in their own equivalent plan.
• Other benefits coverage : Check “Yes” if you are eligible for Unemployment Insurance or Workers’ Compensation benefits during this week. Otherwise, check “No.”
• Dates : Enter the dates for the week. For Paid Leave, a week runs from Sunday through Saturday.
• Do not claim multiple weeks on this form.
• Work Status: For each day of the week, enter one of the following:
• Leave type: For each day that you took paid leave, enter the leave type that you would like to claim for that day. Enter either: Family-Care, Family-Bonding, Medical, Safe, or Pregnancy.

Example
An employee for ABC Corporation took medical leave on Sunday through Wednesday. They did not work any of the days this week and were not eligible to claim Unemployment Insurance or Workers’ Compensation benefits. They have no other employers and their employer does not have an equivalent plan.

WEEKLY CLAIM INFORMATION

CLAIMANT INFORMATION

(To be completed by the claimant) ****

WEEKLY CLAIM INFORMATION

CERTIFICATION

• I certify under penalty of law that the information I have provided is true and correct to the best of my knowledge and belief. I understand the law provides penalties for making false statements in order to obtain benefits through Paid Leave Oregon.

Provide all required information. Missing information can cause a delay in processing your weekly claim.

Mail this form to:
Attn: Paid Leave Oregon
Oregon Employment Department
875 Union St NE
Salem, OR 97311

Need help?
The Oregon Employment Department (OED) is an equal opportunity agency. OED provides free help so you can use our services. Some examples are sign language and spoken-language interpreters, written materials in other languages, large print, audio, and other formats. To get help, please call 833-854-0166 (toll free). TTY users call 711. You can also send an email to paidleave@oregon.gov.
Oregon Employment Department | www.Oregon.gov/Employ | Form 825EN (0823) | Page 4 of 4

References

• Frances Online Landing Page
• Oregon Employment Department : State of Oregon

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