This supplement is attached to and made a part of the Certificate of Insurance, Form DB-820/829, filed for: by and said carrier certifies that benefits are payable to eligible employees at least to the extent described herein. Name of Employer Name of Carrier Employer FEIN WCB Plan # CLASS OR CLASSES OF EMPLOYEES BENEFIT AMOUNT OR RATE EMPLOYEE CONTRIBUTION ELIGIBILITY REQUIREMENT MAXIMUM DURATION (Weeks) NOTICE REQUIREMENT HEALTH INSURANCE Please fill out for Schedule of Paid Family Leave Benefits and Contributions. Disability Benefits Schedule is found on Form DB-820.1. Benefits must be at least as favorable as the requirements of Article 9 of the Workers' Compensation Law. Are there any other benefits, differences or restrictions which are other than those specified in the Disability and Paid Family Leave Benefits Law? If "Yes", list below. Yes NoTHE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATIONPFL-820.1 (3-18)STATE OF NEW YORK WORKERS' COMPENSATION BOARD DISABILITY AND PAID FAMILY LEAVE BENEFITS LAW SUPPLEMENT TO CERTIFICATE OF INSURANCE ATTACH ADDITIONAL SHEETS, IF NECESSARY. American LegalNet, Inc. www.FormsWorkFlow.com PFL-820.1 (3-18) INSTRUCTIONSWEEKLY BENEFIT AMOUNT OR RATE: The minimum acceptable weekly benefit amount is, on or after January 1, 2018, at least 50% of the employee's average weekly wage or 50% of the state average weekly wage, whichever is less. Beginning January 1, 2019, at least 55% of the employee's average weekly wage or 55% of the state average weekly wage, whichever is less. Beginning January 1, 2020, at least 60% of the employee's average weekly wage or 60% of the state average weekly wage, whichever is less. Beginning on January 1, 2021 and thereafter, at least 67% of the employee's average weekly wage or 67% of the state average weekly wage, whichever is less. In all cases, if the employee's average weekly wage is less than $100, the benefit amount must be at least the employee's average weekly wage. DURATION OF BENEFIT (IN WEEKS): Under Section 204 of the WCL, the minimum acceptable duration benefit periods are: on or after January 1, 2018, at least 8 weeks during any 52 week period; on or after January 1, 2019, at least 10 weeks during any 52 week period; and on January 1, 2021, at least 12 weeks during any 52 week period. ELIGIBILITY PERIOD: Employees working a normal work week must become eligible after 26 consecutive weeks of work; those working less than the employer's normal work week must become eligible within 175 days of work (Section 203 of the WCL). If the employee is eligible for paid family leave (after working 26 consecutive weeks or 175 days), there can be no waiting period for paid family leave benefits. EMPLOYEE CONTRIBUTION PER WEEK: If the total amount of employee contributions entered above is in excess of the maximum statutory contributions set annually by the Department of Financial Services pursuant to Section 209 of the WCL, such contributions must be entered into by agreement and reasonably related to the value of the benefits as determined by the Chair under Section 211 of the WCL. NOTICE REQUIRED FOR FORESEEABLE LEAVE: The Policy cannot require an employee to give more than 30 days of notice for foreseeable leave, or as soon as practicable for unforeseeable leave (Section 205 of the WCL). EMPLOYEE HEALTH INSURANCE CONTRIBUTION: If an employee is covered by group health insurance, an employer cannot require an employee on paid family leave to contribute more than the amount he or she did prior to beginning leave. NOTE: The Policy cannot negate the employee's right to reinstatement, to the same or comparable job, on return from paid family leave (Section 203-b of the WCL).DO NOT SCAN American LegalNet, Inc. www.FormsWorkFlow.com