Short Term Disability Claim Form printable pdf download

Short Term Disability Claim Form

UFCW Local 1459 and Contributing Employers Health & Welfare Fund

33 Eastland Street - Springfield, MA 01109-2348

Phone: 413.733.0177 Toll Free: 1.800.634.2700 Fax: 413.733.3325

SHORT TERM DISABILITY CLAIM FORM

SECTION 1 - To Be Completed by Plan Participant

Name

Social Security No.

First

Last

Home Address

City, State Zip

Home Phone (

)

Date of Birth

Name of Employer

Date Illness began or Injury/Accident occurred:

If Injury/Accident, describe HOW and WHERE it occurred (

additional space is available on back of form

Did Injury/Accident occur at work? YES NO

If yes, have you filed a Workers’ Compensation claim? YES NO

Is there anyone that could have caused this injury/accident other than yourself (i.e. third party)? YES NO

If yes, provide name, address and phone number of the third party on back of this form.

Participant’s Signature

Date

SECTION 2 - To Be Completed by Physician

ICD-9 Codes:

Description of Diagnoses:

Is condition a result of patient’s employment YES NO

Date first consulted for this condition:

Date patient has been unable to work from:

Date patient able to return to work (if unknown, provide approximate date):

Date of patient’s next appointment with you:

If maternity, expected date of delivery:

Physician’s Name (Please Print)

Phone No. (

)

Signature of Physician

Date

Address of Physician

City, State ZIP

Payroll / Store Manager see back of form →

Short Term Disability Claim Form