Use this form to apply for disability benefits.
Step 1: Choose how you’d like to submit your claimant form.
Complete a Claimant Statement online through DocuSign.
Make a paper claim
Download and complete a Claimant Statement form.
Note that if you're completing your Claimant Statement online, you'll still need to ask your doctor to complete and return a Physician's Statement to us.
Download this form and print it, or fill it out in Adobe Reader XI or higher Opens a new website in a new window(not your browser) and save. Forms must be signed using a pen, and forms returned with Adobe signature won’t be accepted.
Step 3: Submit your claim.
To submit a paper claim or Physician's Statement please mail, email or fax to the contact information indicated on the claim form.