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:
Download this form and fill it out in Adobe Reader XI or higher (not your browser), and save.
Download the statement, fill it out in Adobe Reader XI or higher (not your browser), and save.
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.
Go to our online claims process, where you will attach all 3 of these forms as part of the submission.
You’ll need to add a few more details about yourself and your plan.
Select submit once you’re done.
If you have questions about submitting online, call us at 1-855-755-6729.
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.