Long-Term Disability Insurance Claim Statement

Personal Information

Full Name Date of Birth Social Security Number Address Phone Number Email Address

Employment Information

Employer Name Job Title Date of Hire Date Last Worked

Disability Information

Nature of Disability Date of Diagnosis Treating Physician Description of Disability and How it Limits Work

Other Income

Are you receiving income from other sources? (e.g., Workers' Comp, Social Security) Yes No If yes, provide details

Authorization & Signature

I hereby certify that the above information is true and complete to the best of my knowledge. Signature Date