Disability Proof of Claim Form
INSTRUCTIONS
Download and print
Disability Proof of Claim Form
Complete Section I and either Section II (work related) or Section III (nonwork related)
Have your physician complete Section IV
Upload your completed form and any other supporting documentation
If injury is work related, upload copy of worker's compensation award and dates of payments (i.e., check copies)
Please upload your completed Disability Proof of Claim Form and any other applicable supporting documentation.
Browse Files
Cancel
of
Employee Signature
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Submit
Should be Empty: