[{"id":"346603a6-7f8d-47e0-81dd-b22f43c11dfe","order":1,"text":"PARENTAL BEREAVEMENT LEAVE","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"0","cflou":false,"active":true},{"id":"9b30c20b-0b4b-4323-8b10-b969261318da","order":2,"text":"REQUEST AND EMPLOYER CONFIRMATION","fontSize":"16","textAlign":"center","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"fecd2454-619b-4084-8fca-308014a36393","order":3,"text":"Made under the Parental Bereavement (Leave and Pay) Act 2018 and the Parental Bereavement Leave Regulations 2020 ("Jack's Law")","fontSize":"11","textAlign":"center","bold":false,"underline":false,"marginBottom":"25","cflou":false,"active":true},{"id":"40ce0914-5c8c-47ef-b82b-7b0e40742d40","order":4,"text":"Employer: [Employer name], of [Employer address] (the "Employer").","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"5ff73cf7-3d08-4da9-83df-1b06c86ae6cb","order":5,"text":"Employee: [Title] [Employee full name], [Job title], payroll / employee reference [Payroll or employee reference] (the "Employee").","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"739bab65-94b0-4f9c-9575-88e00d0233ae","order":6,"text":"Date of this notice: [Date of notice].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"7178a412-d554-4b6b-909b-2cc2a69b148f","order":7,"text":"This form is completed by the Employee to give notice of the intention to take statutory parental bereavement leave, and by the Employer to confirm in writing the leave dates agreed for the purposes of payroll, handover and resource planning. Its purpose is to record the parties' agreement in writing so that the dates approved are certain, evidenced and not left to informal recollection.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"b3f34e43-9e77-411c-a463-75601199077a","order":8,"text":"PART A — NOTICE BY THE EMPLOYEE","fontSize":"16","textAlign":"center","bold":true,"underline":false,"marginBottom":"12","cflou":false,"active":true,"marginTop":"10"},{"id":"f433034f-f07d-4c49-a19a-3ae7c1700332","order":9,"text":"The bereavement","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6"},{"id":"f840fa1d-70aa-4188-894a-66f2af227ff1","order":10,"text":"The Employee gives notice in connection with [loss] of a child. The child's name (where the Employee wishes to record it) is [Child's name (optional)].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"937d1094-fb01-4e3f-8095-39b067286d93","order":11,"text":"The date of the child's death was [Date of death].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"a3cdf7e0-3e98-4670-bdad-b1b879fbf4cd","value":"the death","type":"add","operator":"="}]},{"id":"acc78e5f-991c-447c-a376-5ea1a9b182f4","order":12,"text":"The date of the stillbirth (a stillbirth occurring after the twenty-fourth week of pregnancy) was [Date of stillbirth].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"a3cdf7e0-3e98-4670-bdad-b1b879fbf4cd","value":"the stillbirth","type":"add","operator":"="}]},{"id":"940059b0-658e-4899-a671-3412c6043297","order":13,"text":"The Employee confirms that, at the date of [loss], the child was under the age of 18 (or that the loss was a stillbirth after the twenty-fourth week of pregnancy).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true},{"id":"6a895254-5feb-4516-a746-fe24762a66d6","order":14,"text":"Eligibility for leave","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6"},{"id":"f24000da-a21a-4769-b5b6-835fa3d27ee6","order":15,"text":"Parental bereavement leave is a day-one right: the Employee is entitled to it regardless of length of service. The Employee declares that the Employee qualifies as a bereaved parent of the child by reason of the following relationship: [Relationship to the child].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"9a3194a8-de6d-4724-b5fe-e5b2dfd634a3","order":16,"text":"In making this declaration the Employee confirms that the Employee was, immediately before the child's death or stillbirth, either the parent of the child or a person who had day-to-day responsibility for the care of the child as a primary carer, in accordance with the Parental Bereavement Leave Regulations 2020.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true},{"id":"b6d5c195-79af-47dc-8f87-5ebcaec29237","order":17,"text":"Leave requested","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6"},{"id":"eef68aff-60df-45b3-a5af-1a87e3c093ea","order":18,"text":"The Employee gives notice that the Employee wishes to take [Amount of leave] of parental bereavement leave, [Pattern of leave].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"2f6aaff7-26e9-44c9-8a16-069d39c05063","order":19,"text":"Each week of leave is a period of seven consecutive days and may begin on any day of the week. All parental bereavement leave must begin and end within the period of 56 weeks beginning with the date of the child's death or stillbirth.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b958d431-255e-45de-8a3c-ca60d134e26f","order":20,"text":"First week of leave: from [Start date of first week] to [End date of first week] (inclusive).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"f861cbce-075a-4963-8adb-0432667629ed","order":21,"text":"Second week of leave: from [Start date of second week] to [End date of second week] (inclusive).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true,"displayConditions":[{"field":"28893770-bff3-47b7-ac30-34d5bd851150","value":"as a single block of two consecutive weeks","type":"remove","operator":"="},{"field":"7642d8b7-3cef-41c8-af66-46c80a5d30ae","value":"one week","type":"remove","operator":"="}]},{"id":"33e83915-23ba-438f-a401-e9a081c71309","order":22,"text":"Notice","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6"},{"id":"761b3705-40ef-47e1-9004-d4d20e5fac4b","order":23,"text":"The Employee acknowledges the statutory notice arrangements. Where leave is to begin within the first eight weeks (56 days) after the child's death or stillbirth, the Employee need only notify the Employer before the time the Employee would normally start work on the first day of leave (or, where that is not reasonably practicable, as soon as is reasonably practicable). Where leave is to begin after that initial eight-week period, the Employee must give the Employer at least one week's notice of the intended start date. Leave may be cancelled or rearranged on the same notice.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true},{"id":"cb197673-a5ed-402f-8305-fec93b9b5845","order":24,"text":"Statutory parental bereavement pay","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6"},{"id":"2e0e6d85-9da2-4436-98d2-905c51bf1ee4","order":25,"text":"The Employee wishes to claim statutory parental bereavement pay (SPBP) for the period of leave and, by signing this Part A, gives written notice of that claim.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"742e4534-ffbb-47fb-9e28-67b495d211ff","value":"No","type":"remove","operator":"="}]},{"id":"f585a198-a93a-4196-92b4-2727454c14f9","order":26,"text":"The Employee declares, for the purpose of claiming SPBP, that: (a) the Employee has been continuously employed by the Employer for a period of at least 26 weeks ending with the relevant week before the child's death or stillbirth; (b) the Employee's normal weekly earnings for the relevant period were not less than the lower earnings limit for National Insurance contributions; and (c) the Employee meets the relationship conditions stated above.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"742e4534-ffbb-47fb-9e28-67b495d211ff","value":"No","type":"remove","operator":"="}]},{"id":"78138ab3-bfbf-442d-bfc5-a107d66ee012","order":27,"text":"The Employee's National Insurance number is [National Insurance number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"742e4534-ffbb-47fb-9e28-67b495d211ff","value":"No","type":"remove","operator":"="}]},{"id":"38c63940-a74c-4aa4-953d-041c528df58a","order":28,"text":"Written notice to claim SPBP must be given within 28 days of the first day of the period of pay to which it relates. SPBP is payable at the lower of the prescribed statutory weekly rate (for the 2025/26 tax year, £187.18 per week) and 90% of the Employee's average weekly earnings, for up to two weeks. Any contractual enhancement above the statutory rate is a matter for the Employer's policy and is recorded, if applicable, in Part B.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true,"displayConditions":[{"field":"742e4534-ffbb-47fb-9e28-67b495d211ff","value":"No","type":"remove","operator":"="}]},{"id":"9a806f08-b2d9-4513-8eea-176d945b38f8","order":29,"text":"The Employee does not claim statutory parental bereavement pay in respect of this leave. The Employee's day-one right to take the leave is unaffected, and the leave will be unpaid unless any contractual entitlement applies under the Employer's policy.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true,"displayConditions":[{"field":"742e4534-ffbb-47fb-9e28-67b495d211ff","value":"Yes","type":"remove","operator":"="}]},{"id":"801b6217-808a-49d6-bed2-572092f0422c","order":30,"text":"Employee declaration and signature","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6"},{"id":"5b5010ae-7a8f-4faa-a1cf-ddd39608f9ab","order":31,"text":"The Employee confirms that the information given in this Part A is true and accurate. The Employee understands that this notice is given in connection with a statutory entitlement and that the Employer is entitled to rely on it for payroll and record-keeping purposes.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"fc92940f-256f-48a0-8c01-2f2e04cffc6b","order":32,"text":"Signed by the Employee: ____________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"438f05d9-f5e2-4f94-bfc9-a2172c7eb0d3","order":33,"text":"Name: [Employee full name] Date: [Date of employee signature]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"c024d351-d2bd-4654-bcb2-25b67223f808","order":34,"text":"PART B — CONFIRMATION BY THE EMPLOYER","fontSize":"16","textAlign":"center","bold":true,"underline":false,"marginBottom":"12","cflou":false,"active":true,"marginTop":"10","displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"354c2ec8-0b1e-41a4-b741-15a5399e60ad","order":35,"text":"The Employer acknowledges receipt of the Employee's notice and confirms the arrangements set out below. The Employer notes that parental bereavement leave is a statutory entitlement and that the dates requested by the Employee cannot be refused; the purpose of this confirmation is to record the agreed dates for payroll, handover and planning.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"2995bd31-ebbe-4f62-99f8-9ee7d2d50f4c","order":36,"text":"Confirmed leave dates","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6","displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"5e125ccf-7b8f-4fb6-aab9-07118054d1f6","order":37,"text":"The Employer confirms the following approved leave: [Confirmed leave dates].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"15b2ffd5-62dd-42ca-b816-9a38c9b22213","order":38,"text":"Pay treatment for the period of leave: [Pay treatment].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"e0d62e9c-298e-4075-a6e3-37dc59c6bc72","order":39,"text":"Cover and handover arrangements during the leave: [Cover and handover arrangements].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"67b16c6f-f6b3-4a7c-9f46-b2b2831595f5","order":40,"text":"Protection of the Employee","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6","displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"861a2eca-7a81-4c0f-831a-f1fa4fa26030","order":41,"text":"The Employer confirms that the Employee will not be subjected to any detriment, and will not be dismissed, for taking or seeking to take parental bereavement leave. The Employee retains the right to return to the same job on terms and conditions no less favourable than those that would have applied had the Employee not been absent.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"0e616860-3962-4167-8943-fa2ca561995e","order":42,"text":"Data protection","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6","displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"1a2db82b-9874-483b-a0da-babe77ff3987","order":43,"text":"Personal data provided on this form (including the information relating to the child and the Employee's National Insurance number) will be processed by the Employer only for the administration of the Employee's leave and pay and for compliance with the Employer's legal obligations, in accordance with the UK General Data Protection Regulation and the Data Protection Act 2018. Such data will be retained for no longer than is necessary for those purposes and for the statutory record-keeping period.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"f0dca12f-d73f-46e3-ac9e-fe5992ed0adf","order":44,"text":"Employer signature","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"8","cflou":false,"active":true,"marginTop":"6","displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"32cf5d76-19e5-4de3-848e-c10d2fb53bad","order":45,"text":"Signed for and on behalf of the Employer: ____________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"14c22223-1131-4625-b91b-93c39d5294f8","order":46,"text":"Name: [Name of signatory] Position: [Position of signatory]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"a4ccbbb6-35aa-461c-88d2-ba22e86abd0b","order":47,"text":"Date: [Date of employer signature]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"9bd49260-c5f3-415e-a270-d9bf0dec9a7a","value":"No","type":"remove","operator":"="}]},{"id":"68e5bbf2-709f-49b4-a27d-5ea07c435108","order":48,"text":"This form records statutory entitlements under the Parental Bereavement (Leave and Pay) Act 2018 and the Parental Bereavement Leave Regulations 2020. Nothing in it limits any greater contractual right the Employee may have under the Employer's policies or contract of employment.","fontSize":"11","textAlign":"center","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true,"marginTop":"10"}]