Division of Temporary Disability and Family Leave InsuranceURL reading ( My Leave Benefits . NJ . Gov )

Print an Application

Photo: Printer with hands collecting printout

Start here to apply by mail or fax.

Printable application forms can be mailed to the address or faxed to the number on on each form.

Note: Only applications submitted online will get confirmation of receipt. 

An African-American man with an injured leg doing physical therapy

Temporary Disability Insurance Application (DS-1)


Smiling elderly Asian woman in a wheelchair in front of her house, with her daughter kneeling beside her

Family Leave Insurance Application (FL-1)