Mental Health Disability Insurance Claim Statement
1. Personal Information
Full Name
Date of Birth
Policy Number
Contact Number
Email Address
Address
2. Employment Information
Employer Name
Job Title
Start Date
Current Work Status
Last Day Worked
3. Details of Disability
Primary Mental Health Diagnosis
How does this condition affect your ability to work?
Date Symptoms First Appeared
Date Diagnosed
4. Healthcare Provider Information
Treating Doctor / Mental Health Professional
Practice Name
Contact Number
Last Consultation Date
Treatment(s) Received
Medications Prescribed
5. Additional Information
Other relevant information or comments
6. Declaration
Signature
Date