Disability Insurance Employer's Statement for Faculty,Officers, Exempt Professionals - University of 2026

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  1. Click ‘Get Form’ to open the Disability Insurance Employer's Statement in the editor.
  2. Begin by entering the employee’s full name and Social Security number at the top of the form. Ensure that all personal information is accurate.
  3. Fill in the employment details including job title, date employed, and work location. Attach a copy of the job description as required.
  4. Indicate whether the employee is insured for Short Term Disability and Long Term Disability by checking 'Yes' or 'No' and providing effective dates.
  5. Complete sections regarding any other benefits received by the employee that may affect their disability claim, such as Workers’ Compensation or Social Security.
  6. Review all entries for accuracy before signing. The employer representative must sign and date the form to certify its completeness.

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