To submit the form, ensure it's completely filled out by you, your employer, and your doctor. Email the completed form to the specific insurance carrier listed on the document, or fax it to the indicated number. Alternatively, you may submit it physically to the designated address for processing.

Ensure you follow deadlines related to claims submission within 90 days after your disability begins. Keep track of any additional required information, as timely submission can be critical for benefit eligibility.

The primary purpose of this form is to provide a structured approach for employees to claim disability benefits. It ensures that all necessary information is collected from the claimant, the employer, and the healthcare professional. This comprehensive documentation facilitates efficient handling of disability claims, ensuring that employees receive their entitled benefits promptly.

• 1. Claimant's Statement: Basic personal details including name, contact information, and disability description.
• 2. Employer's Statement: Employer's specific information and wages of the claimant.
• 3. Doctor's Statement: Medical validation regarding the claimant's ability to work.

Failing to submit the form on time can delay the approval of benefits, leading to financial hardship for claimants. It's crucial to ensure all sections are accurately completed and submitted within the set deadline.

• Delayed Benefits: Late submission can result in delayed access to necessary financial support.
• Increased Stress: Financial uncertainty may lead to increased stress during recovery periods.
• Complicated Appeal Process: Failure to submit properly may lead to complicated appeal processes to receive benefits.

• 1. For Employee Use: Employees should fill this form when unable to work due to sickness or injury.
• 2. For Employers: Employers must use this form to validate and support employee claims.
• 3. For Medical Professionals: Medical providers utilize this form to confirm patient disabilities.