Sick Leave Claim Form Disability Extension Application 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part 1 - Employee Section. Fill out your personal contact information, ensuring all fields are legible. Check the box indicating if this is an address change.
3. In Section 1-B, accurately enter the dates of your illness, injury, or disability. Ensure that the last day worked and first date absent match.
4. Complete Section 1-C by confirming whether the illness is your own and providing any necessary details regarding previous claims or work-related injuries.
5. Sign and date in Section 1-D to certify your request for sick leave or disability extension.
6. If applicable, have your employer fill out Part 2, ensuring they provide accurate schedule and pay information before signing.
7. Finally, if required, ensure that a physician completes Part 3 with their certification and signature.

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