Disabled Member Application
Thank you for your interest in applying for Disabled Member status. Disability requires the written validation from a physician that the member is no longer able to work in any setting of gainful employment and become classified as handicapped according to the Americans with Disability Act Standards.
Requirement:
Date:
*
Today's Date
Name
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
Email Address:
*
Upload letter of petition, include date disability began.
*
Browse Files
Cancel
of
Upload physician certification of the disability.
*
Browse Files
Cancel
of
Save
Submit
Should be Empty: