Weekly disability benefits initial statement of claim form 2025

1. Click ‘Get Form’ to open the weekly disability benefits initial statement of claim form in the editor.
2. In Part I, enter the insured's name, date of birth, and social security number. Ensure all fields are completed accurately to avoid delays.
3. For employers, complete and sign Part I, attach a job description, and provide proof of earnings such as payroll records or W-2 forms.
4. In Part II, the insured must fill out their home address and answer questions regarding their employment status and medical condition.
5. Complete the AUTHORIZATION FOR USE IN OBTAINING INFORMATION form by signing it to allow access to necessary medical information.
6. Ensure that the attending physician completes and signs the ATTENDING PHYSICIAN STATEMENT, providing all required details about the patient's condition.
7. Review all sections for completeness before submitting. You can easily save your progress on our platform at any time.

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