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Click ‘Get Form’ to open the Sick Benefits Application in the editor.
Begin by filling out Part 1, which requires your personal information. Enter your name, address, account number, city, state, and zip code in the designated fields.
Provide your home phone number and location (Depot, Department, Shop) along with your position and date of hire.
Describe the nature of your problem (e.g., Auto Accident, illness) in the provided space. Indicate if you have a pending Workers' Compensation Claim by checking 'Yes' or 'No'.
Review the FMLA eligibility section carefully. Acknowledge that applying for Sick Benefits may affect your FMLA leave entitlement.
Sign and date the form at the bottom of Part 1 before submitting it to your Location Manager for approval.
Ensure that your health care provider completes Part III on the reverse side of this form accurately.
Once completed, fax the application to SEPTA Benefits at (215) 580-7185 and AmeriHealth Casualty at (215) 587-1284 as instructed.

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