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The document outlines the procedures and requirements for filing a Short-Term Disability Benefit Claim with the District Council 37 Health & Security Plan. It includes sections for employee information, illness details, and an attending physician's statement, emphasizing the need for accurate completion and timely submission of forms to avoid delays in processing claims.

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Click ‘Get Form’ to open the Short-Term Disability Benefit Claim form in our editor.
Begin by filling out your personal information in the 'Employee Information' section. Enter your name, Social Security number, home address, and date of birth.
In the 'Job Information' section, provide details about your workplace, including the name of your employer, job title, and department. Make sure to include your employment start date and annual salary.
Next, complete the 'Illness Information' section. Indicate whether you have returned to work and provide details about your illness, including when you first saw a doctor.
If applicable, fill out the sections regarding hospitalization or accidents. Be specific about dates and circumstances surrounding your disability.
Finally, review all entered information for accuracy before signing electronically at the designated area. Ensure that all required fields are completed to avoid delays in processing.

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