Short Term Disability Insurance Program

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COUNTY OF INYO
SHORT-TERM DISABILITY INSURANCE PROGRAM
Employee Application for Benefits
Employee’s Name: ________________________________ Home/Cell Phone #___________________
Mailing Address: _______________________________________________________________________
Position Title: ____________________________ Employing Department: __________________________
Date of Birth: ________________________What was the last date worked? ________________________
What was the first day you were too sick or injured to perform the normal duties of your job (even if it was a
weekend, holiday, or normal day off)?_____________________________
Please state the name(s) and address(es) of all physicians that are treating you for this condition:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Have you recovered from this disability? Yes
No
If so, give a date of recovery: __________________
If so, have you filed a Worker’s Compensation
Was this disability caused by your work? Yes
No
claim? Yes
No
Do you have any other disability insurance policy? Yes
No .
If so, state policy number, company
name, and address:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
I hereby apply for benefits under Inyo County’s Short Term Disability Program. I declare, under penalty of
perjury, that the foregoing statements are true, complete, and correct, to the best of my knowledge. I
authorize my attending physician, medical practitioner, hospital, or other medical provider to furnish and
disclose all facts, records, and reports concerning my disability, and release such providers from any liability
resulting from the use of this information. This authorization is valid for a period of 18 months from the date
of my signature or the effective date of the claim, whichever is later. I agree that photocopy of this release
shall be as valid as the original.
Employee’s Signature________________________________________ Date_______________________
Employee: Have your physician complete the “Physician’s Certificate of Disability” on the reverse side of
this form and return it to:
Inyo County Personnel Department
P.O. Box 249
Independence, CA 93526
IMPORTANT: The claim must be mailed within 49 days of the date you became disabled if you are to receive credit from the
date you first became disabled. If the claim is mailed late and you believe that you have “good cause”, you should include an
explanation on a separate sheet attached to the claim form.

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