Short-Term Disability Claim Form
Personal Information
Full Name
Date of Birth
SSN / Employee ID
Address
Phone
Email
Employment Information
Employer Name
Position / Job Title
Date Hired
Average Weekly Hours
Employment Status
Full-Time
Part-Time
Other
Disability Claim Information
First Day Unable to Work
Expected Return Date
Disabling Condition
Description of Disability / Illness
Treating Physician
Physician Phone
Physician Address
Authorization & Signature
Signature
Date