Sick Leave Claim Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. 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.
5. Sign and date in Section 1-D to certify your request for Sick Leave payments or Disability Extensions.
6. If applicable, have your employer complete Part 2 and ensure they sign and date it after your first day absent.
7. Finally, if required, have your physician fill out Part 3 with their certification of your condition.

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