New York Paid Family Leave Deduction Setup Form

New York Paid Family Leave Deduction Setup Form
Client Number:
Client Name
Company Number:*
Company name*
Date Requested*

MonthDayYear
Date
Change Effective Date*

MonthDayYear
For proper audit, Asure requires advance notice for company changes.
Notes
Indicate type of change*
Code: (Asure will assign) Code Type: DN Description: NY PFL
Auto create on all new hires?
Will employer pay a portion of this deduction?
What percentage will the employer pay?
Employee Deduction G/L #
Add to Custom Writer Report(s)?
Please specify all custom reports to be reviewed
I agree to and authorize Asure to make the above changes to our company set up.
Authorized Client Representative*
Title*
Signature*
The individual signing this document on behalf of a corporate party warrants that he or she has full authority to sign this document. Company acknowledges that receipt by Asure of a copy of the Agreement, by facsimile, shall constitute the legal equivalent, for all purposes, of receipt of an original Agreement. Company also acknowledges that Asure may require the use of an electronic signature procedure as an alternative method to obtain the execution of the Agreement of Company. Company agrees that the Agreement shall not be denied legal effect, validity or enforceability solely because an electronic signature or electronic record was used in its formation. Company agrees that Asure shall be entitled to rely on said facsimile Agreement, or said electronic signature, and further agrees to hold Asure harmless and indemnify Asure from any and all claims, injuries and damages, of any nature incurred or suffered by Asure as a result of its reliance upon said facsimile transmission or said electronic signature. This Agreement shall be construed and governed under the laws of Vermont.
Should be Empty: