Group Disability Insurance Claim Statement

Employee Information

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

Employment Information

Employer Name Occupation/Job Title Date of Employment Last Day Worked Work Schedule (Hours/Week) Is your disability work related? Yes No Unknown

Disability Information

Date Disability Began Date First Treated Nature of Illness/Injury Description of Disability Treating Physician Name Physician Phone Physician Address

Other Income Benefits

Are you receiving or applying for: (Check all that apply) Workers’ Compensation
Social Security Disability Insurance
State Disability Benefits
Other (specify)

Authorization & Signature

Signature Date