Employer Statement
for Disability Insurance
Employee Information
Employee Name
Employee ID
Department
Position/Title
Date Hired
Employer Information
Employer Name
Address
Phone
Email
Employment Details
Last Day Worked
Reason for Absence
Is Employee Expected to Return?
Salary Information
Salary or Hourly Rate
Average Weekly Hours
Date Salary Began
Remarks/Additional Comments
Employer Signature
Date
Title