UEBT SICK LEAVE CLAIM FORM DISABILITY EXTENSION APPLICATION 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part 1, where you will fill out your personal information. Include your last name, first name, date of birth, and social security number. Ensure that your mailing address is accurate and check if there has been a change.
3. In section 1-B, indicate the first date you were absent due to disability and your expected return-to-work date. If applicable, confirm whether the injury occurred on the job.
4. Complete section 1-C by providing the injury date and confirming if you consulted a doctor during your disability period.
5. In Part 2, your employer will need to fill out their section. They should provide details about your scheduled work hours and any relevant information regarding your absence.
6. Finally, ensure that all sections are signed appropriately before submitting the form as instructed at the end of the document.

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