Group Disability Insurance Claim Form
Employer Information
Employer Name
Policy Number
Employer Address
Contact Person
Contact Email
Contact Phone
Employee Information
Employee Name
Employee ID
Date of Birth
Address
Phone
Email
Disability Details
Date Last Worked
Date Disability Began
Nature of Disability
Description of Disability
Has employee returned to work?
Yes
No
If yes, date returned
Physician/Medical Information
Physician Name
Phone
Address
Authorization & Signature
Authorization Statement
Employee Signature
Date