Short Term Disability Claim Form (Page 4 of 7) in pdf

Short Term Disability Claim Form



13. Have you ever had the same or a similar condition in the past?

Yes

If yes, when?

Please list name, address, and telephone number of all physicians consulted.

14.

As a result of this disability, are you, your spouse or any of your dependent children receiving income from any of the following?

AMOUNT

PAID WEEKLY

PAID MONTHLY

DATE BEGAN

DATE TERM.

Yes



 Sick Pay

___________ ____________

$ _____________



 Salary Continuance Benefits

___________ ____________

$ _____________



 Workers' Compensation

___________ ____________

$ _____________



 Local, State or National Association or

___________ ____________

Society Disability Income Plan

$ _____________



 No-fault

___________ ____________

$ _____________



 Unemployment Compensation disability $ _____________

___________ ____________



 Social Security Benefits

___________ ____________

(disability or retirement)

$ _____________



 Retirement income (normal, early,

___________ ____________

or disability)

$ _____________



 Other LTD/STD Benefits

___________ ____________

$ _____________



 Other (describe)

___________ ____________

$ _____________

Have you applied, or do you plan to apply for benefits described above? 



15.

Yes

Type _________________________________________________ Date application filed __________________

I affirm the above information is true and complete to the best of my knowledge.

Claimant’s Signature

Date

(If claimant is unable to sign, state reason and specify signer’s relationship to the claimant.)

Short Term Disability Claim Form Page 4

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