Long-Term Disability Insurance Claim Statement
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Policy Number
Employment Information
Employer Name
Job Title
Employment Start Date
Employment Status
Full-Time
Part-Time
Other
Last Day Worked
Disability Details
Primary Diagnosis / Condition
Date of Disability Onset
Cause of Disability (Describe)
Treating Physician(s)
Treatment Details
Other Income Sources
Are you receiving any other disability or income benefits?
Yes
No
If yes, please provide details
Additional Information
Additional Comments
Signature
Date