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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the Employee Section. Enter your name, plan number, and home mailing address. Ensure all fields are completed accurately to prevent processing delays.
- Provide your date of birth and social security number. This information is crucial for identity verification.
- Indicate whether your disability is due to employment or an accident by selecting 'Yes' or 'No'. If applicable, provide additional details regarding any workers' compensation claims.
- Complete the Physician Section if required. Your physician will need to fill in diagnosis, treatment dates, and confirm your disability status.
- Finally, review all sections for accuracy before submitting. Use our platform’s features to save and share the completed form easily.
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