Short-Term Disability Insurance Claim Form
Personal Information
Full Name
Date of Birth
Social Security Number
Address
Phone Number
Email
Employment Information
Employer Name
Employer Address
Employer Phone
Job Title
Date Employment Began
Disability Information
Type of Disability
Date Disability Began
Expected Return to Work
Treating Physician Name
Physician Phone
Describe Your Disability
Authorization & Signature
Signature
Date