Disability Allowance Form Page 28
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36589DF476
Your education and work history and how your medical
Part 10 continued
condition affects the activities of your typical day
2(g). Please provide an outline of your activities during a typical day and any other relevant
information?
2(h). How often do you visit your doctor?
Weekly
Monthly
Less often
2(i). Are you currently on medication?
Yes
No
If ‘Yes’, please give details in the space provided:
The information provided will be treated in the strictest confidence
9071043554
9071043554
9071043554
9071043554
Before submitting this application please ensure that you supply all
information requested in this form and that you and your Doctor submit
comprehensive information on your medical condition. This will result in your
claim being processed in a timely manner and allow for a better quality
decision on your claim.
Page 26
821F2D5D
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal