Disability Insurance Proof of Loss Statement
Personal Information
Full Name
Date of Birth
Address
Phone Number
Policy Number
Disability Information
Date Disability Began
Cause of Disability
Diagnosis
Describe Treatment
Physician Information
Attending Physician Name
Physician Contact
Physician Address
Employment Information
Employer Name
Occupation
Last Day Worked
Expected Return to Work Date
Certification
I certify that the information provided is true and correct:
Signature
Date