Disability benefits claim forms
How to make a claim
Use these forms to claim income benefits if you have short-term, long-term or early referral services disability coverage through your employer or plan sponsor.
To make a claim for coverage through your employer/plan sponsor, follow these steps:
Step 1: Complete a consent form.
Download this form and fill it out in Adobe Reader XI or higher - Opens in a new window (not your browser), and save.
Step 2: Complete an employee statement.
Download the statement, fill it out in Adobe Reader XI or higher - Opens in a new window (not your browser), and save.
Step 3: Request a completed physician’s report.
Select the most appropriate form for your condition and ask your doctor to complete it.
If you’re missing work because you have a COVID-19 diagnosis or pending test, you can complete this step yourself, without a doctor’s help.
Note: The signatures are still required but we’ll contact you later to complete these. You can submit your claim without them for now.
It’s best to submit online, but you have options if you can’t.
You can mail or fax your forms to your local disability management services office. Please be aware that the response might be delayed right now.
Waiting for a response?
If you have questions about your claim or want to know its status, call or email your local disability management services office.