Residual Disability Benefits Claim Statement
Personal Information
Full Name
Date of Birth
Policy Number
Contact Number
Address
Claim Details
Date Disability Began
Diagnosis
Treatment Received
Attending Physician
Work Information
Occupation
Employer
Description of Duties
Gross Monthly Income Before Disability
Gross Monthly Income After Disability
Statement
Please explain how your disability affects your ability to work:
Authorization
Signature
Date