Mental Health Disability Insurance Claim Form

Personal Information

Full Name Date of Birth Address Phone Number Email Address Policy Number

Employment Information

Employer Name Occupation Last Day Worked Employment Status Full-time Part-time Other

Medical Information

Diagnosis Date Symptoms Began Treating Provider Name Provider Address Treatment Details

Claim Details

Reason for Claim Duration of Absence (if known) Additional Comments

Authorization & Signature

I certify that the information provided is true and complete. Signature Date