Application For Weekly Income Disability Benefits Form - Alaska Electric Health & Welfare Fund
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2Alaska Electrical Health & Welfare Fund
2600 Denali Street, Suite 200
Anchorage, AK 99503-2782
(907) 276-1246 • (800) 478-1246 • FAX (907) 278-7576
APPLICATION FOR WEEKLY INCOME DISABILITY BENEFITS
INSTRUCTIONS TO PARTICIPANT
1. This form is to be filed as soon as it appears that you will qualify for disability benefits.
To qualify, you must be totally and continuously disabled from performing the duties of your
occupation because of injury or illness and not engaged in any other occupation for wage or profit.
2. You are to complete front side answering all questions in detail.
3. Your physician must complete the reverse side answering all questions in detail.
4. Return the completed form to the Alaska Electrical Trust Funds.
Part 1-TO BE COMPLETED BY PARTICIPANT:
_______________________________________________
__________________________________________
Name
Social Security Number
____________________________________________
_____________________
________
__________
Mailing Address
City
State
Zip Code
Home:______________________
Work:_____________________
________________________________
Telephone Number
Date of Birth
____________________________________________
____________________________________
Current Employer
Occupation
When did you become totally disabled and unable to work? Date:_______________________________________
Has your disability been total and continuous since you became unable to work?
Yes
No
If yes, approximately when do you feel you will be able to resume work? __________________________________
If no, when did you again become able to work? Date: _____________________Hour: ________
A.M.
P.M
Is disability due to:
Accident
Sickness
(If accident, describe, including date and place. If sickness, when did symptoms
________________________________________________________________________________
first appear?)
___________________________________________________________________________________________
Have you been hospital confined?
Yes
No If yes, when? From______________ to __________________
Name of hospital:_____________________________________________________________________________
Address
Did disability result from employment?
Yes
No
If yes, give amount of weekly benefit you are receiving from Workman’s Compensation and forward a copy of the
award: $_____________________________
Your attending physicians during the past year:
Medical Condition:
Date consulted:
______________________________________
________________________
____________________
______________________________________
________________________
____________________
These statements are true and complete to the best of my knowledge.
I hereby authorize any Plan Administrator, insurer, physician, hospital, or Workman’s Compensation carrier to disclose
and release any information acquired in the course of my examination or treatment.
Participant Signature:__________________________________________
Date:_________________________
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