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Paid Familyand Medical Leave (PFML) Application <br />Application is hereby made fora plan of Paid FamilyandMedical Leave based on the statementsand representations <br />contained herein. Thisapplication becomes part of the policy.Retain a signed copy for your records. <br />Full Legal BusinessName <br />CityofCenterville <br />Business AddressMailing Address (if not the same) <br />1880MainSt. <br />CityStateZipCityStateZip <br />CentervilleMN55038 <br />Phone <br />Applicant E-mailAttention/Care of <br />Phone <br />(651)429-3232 <br />Applicant Website Address <br />Legal Entity Type (Choose one) <br />Sole Proprietor Partnership Corporation Association Limited Partner (LP) Joint Venture (JV) <br />Limited Liability Co. (LLC)Trust or Estate Executor or Trustee Limited Liability Partnership (LLP or LLLP) Other <br />Nature of BusinessSIC CodeFederal ID #Unemployment Insurance # <br />LocalGovernment9199 <br />Requested Effective DateCurrent PFMLCarrier <br />1/1/2026NA <br />COVERED EMPLOYEES <br />All employees, pursuant to Paid Family, and MedicalLeave law are covered: <br />Number of Covered Males <br />Number of Covered Females <br />Total Employees <br />EMPLOYEE CONTRIBUTION <br />Paid Family and MedicalLeave NoncontributoryContributory <br />Proprietors: If Business Entity is a Proprietorship, list Names of Proprietors below. <br />SPLPFML A1 02 <br />80 <br /> <br />