Self-Employed Disability Claim Statement
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Business Information
Business Name
Type of Business
Business Address
Years in Operation
Average Annual Income
Disability Details
Date Disability Began
Nature of Disability
Describe Your Disability and How It Affects Your Ability to Work
Last Date Worked
Medical Provider Information
Physician/Treatment Provider Name
Contact Information
Additional Information
Additional Comments
Signature
Date