Disability Appeal Form For South African Local Authorities Pension Fund Members Page 3

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Telephone numbers
During Office hours
Code
Alternate contact number
Code
Home
Code
Cell
Date of employment
Date of initial Disability
Application
APPEAL APPLICATION
Please explain in your own words how your incapacity affects your ability to perform the
duties of your own occupation
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Have your symptoms or condition worsened since your initial application for disability
benefits? Yes / No
___________
If yes, please detail this deterioration in your own words
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
INFORMATION AFTER INITIAL APPLICATION FOR DISABILITY INCOME
BENEFITS:
State the name and address of doctor(s) and the dates on which you have consulted them after
your initial application for disability benefits was repudiated (please include all additional new
reports) :
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Appeal Application Form
Page 3 of 5
Strictly Private and Confidential

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