Supplemental Disability Insurance Claim Statement
1. Personal Information
Full Name
Date of Birth
Policy Number
Address
Phone
Email
2. Claim Details
Date of Injury/Illness
Type of Disability
Is condition work-related?
Yes
No
Description of disability (include symptoms, diagnosis, and date symptoms began)
3. Employment Information
Employer Name
Occupation/Job Title
Last Day Worked
Duties unable to perform
4. Physician Information
Physician Name
Phone
Address
Dates of Treatment
5. Additional Information
Any other insurance coverage?
Yes
No
Notes or comments
6. Authorization & Signature
Signature
Date