Employer’s Disability Claim Certification Form
Employee Information
Full Name
Employee ID
Job Title
Department
Date Hired
Last Day Worked
Disability Information
Type of Disability
Date Disability Began
Expected Return to Work Date
Additional Details
Employer Details
Employer Name
Address
Phone / Email
Certification
I certify that the above employee's statement is correct to the best of my knowledge.
Employer Signature
Date