Short-Term Disability Claim Statement
Employee Information
Full Name
Employee ID
Date of Birth
Phone Number
Address
Employment Information
Employer Name
Department
Job Title
Employment Status
Full-Time
Part-Time
Contract
Other
Disability Details
Date Disability Began
Nature of Disability / Illness
Treating Physician's Name
Physician Contact Number
Treatment Details
Estimated Return to Work Date
Authorization & Acknowledgment
I certify that the information provided is true and complete to the best of my knowledge. I authorize the release of medical and employment information as necessary to process my claim.
Signature
Date