Short-Term Disability Employee Request - teamsters145 2026

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The document is a Short-Term Disability Employee Request form that employees must complete to request benefits for a disability period lasting up to seven days. It includes sections for employee information, claim details, tax withholding, and authorization for healthcare providers to share medical information. Additionally, it outlines eligibility criteria for benefit payments related to non-occupational illnesses or injuries and requires an Attending Physician's Statement to be filled out by the physician.

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Click ‘Get Form’ to open the Short-Term Disability Employee Request in the editor.
Begin by filling out the 'Employee Information' section. Enter your Social Security Number and full name accurately.
In the 'Claim Information' section, indicate whether your absence is work-related by selecting 'Yes' or 'No'. If applicable, provide details about any accidents.
Describe the nature of your illness or injury in the designated field. Be specific about how, when, and where it occurred.
Complete the 'Federal & State Income Tax Withholding' section if you are eligible for short-term disability benefits. Ensure that your W-4 form is on file.
Sign and date the release authorization to allow healthcare providers to share necessary information regarding your claim.
Finally, review all entries for accuracy before submitting your completed form through our platform.

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2014	4.8 Satisfied (116 Votes)

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What justifies short-term disability?

To qualify for short-term disability benefits, an employee must be unable to do their job, as deemed by a medical professional. Medical conditions that prevent an employee from working for several weeks to months, such as pregnancy, surgery rehabilitation, or severe illness, can qualify to receive benefits.

How do I tell my boss I need short-term disability?

Notify your manager and your leave of absence specialist or local HR Office of your need for Short Term Disability (STD) at least 30 days in advance of your anticipated last day of work, if possible, to discuss your options.

How do I ask for short term disability?

If you are applying for short-term disability, you have to go through your employer, who will tell you what paperwork needs to be filled out. You will then have to make an appointment to see your medical provider to discuss your request and ask them to fill out the required paperwork.

What documentation is needed for short-term disability?

UPS EMPLOYEES ONLY: In addition to submitting your claim form to TeamCare, UPS employees must also call Aetna at 866-825-0186 to initiate your leave with UPS. General questions about your leave from UPS should be directed to Aetna at 866-825-0186.

How do I tell my boss I am going on short term disability?

Attending Physicians Statement (APS). This form provides us with specific medical information about your condition and expected recovery. Employers Statement. This form provides us with information on your claim and on your employment, salary, benefits, and other sources of income.

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