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The document is a Sick Leave/Disability Extension Form Checklist that outlines the necessary steps and information required for employees to complete their sick leave or disability claims. It includes sections for employee personal information, illness or injury details, employer verification, and physician certification. Key points include the need for signatures, deadlines for filing claims, and requirements for state disability insurance if absences exceed seven days. The checklist aims to ensure that all necessary documentation is provided to facilitate quick processing of claims.

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Click ‘Get Form’ to open it in the editor.
Begin with Part 1, Employee Section. Fill in your personal contact information, ensuring all fields are legible. If this is an address change, check 'Yes' and provide the effective date.
In Section 1-B, enter the dates of your illness, injury, or disability. Ensure that the Last Day Worked and First Date Absent match the Employer's section.
Complete Section 1-C by confirming if your condition is related to a previous claim within 60 days and provide details if you were injured on the job.
Sign and date in Section 1-D to certify your request for Sick Leave payments or Disability Extensions.
If applicable, have your employer complete Part 2 and ensure they sign and date it after your first day absent.
Finally, if required, have your physician fill out Part 3 with their certification of your condition.

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