Permanent Total Disability Claim Statement
Personal Information
Full Name
Date of Birth
Policy Number
Address
Phone Number
Email Address
Disability Details
Date Disability Commenced
Nature and Cause of Disability
Is the Disability Permanent and Total?
Yes
No
Has the disability prevented you from working? If yes, explain:
Name and Address of Treating Physician
Date First Seen by Physician
Employment Details
Occupation at Time of Disability
Employer Name
Employer Address
Last Date Worked
Other Insurance
Are there other insurance policies covering this disability?
Yes
No
If yes, list insurer(s) and policy number(s)
Declaration & Authorization
I declare the information provided above is true and complete to the best of my knowledge.
Signature
Date