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Click ‘Get Form’ to open the life disability claim form in the editor.
Begin by filling out the Member’s Statement section. Provide your Social Security Number, name, address, and contact information accurately.
Complete the sections regarding your employment status, including your employer's name and whether you are self-employed. Specify the date you last worked and your normal working hours.
Detail your disability by indicating its nature and whether it was due to an accident. Include dates of treatment and any attempts to return to work.
Fill in the Medical Provider’s Statement section by having your medical provider complete their part. Ensure they sign and date where required.
Review all entries for accuracy before signing at the bottom of Page 3 and completing the Authorization for Release of Information on Page 4.
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