Get Claimant And Employer Statement

Completing the Claimant And Employer Statement is an essential step in the claims process. This guide will provide users with clear and supportive instructions on how to efficiently fill out this form online, ensuring that all necessary information is accurately submitted.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the Claimant And Employer Statement and open it for editing.
2. Begin with Section A, which must be completed by the Policyholder. Fill in the name of the Policyholder, their sex, marital status, and date of birth. Indicate if the claim is for self or a child, and provide details such as the child's name, date of birth, and social security number if applicable.
3. In the same section, indicate the type of claim (sickness or accident) and provide specific details about the accident, including the date and circumstances surrounding it.
4. Next, navigate to Section B, which can be filled out by either the Policyholder or Claimant. Here, you must authorize the release of information. Carefully read the authorization statement and provide your signature, the date, and your address.
5. Continue in Section B by certifying the information provided is true and complete. This section also requires your signature, date, and contact address.
6. Proceed to Section C, which is to be completed by the Employer’s Authorized Representative. This individual will provide information about the employee's current employment status and nature of their disability.
7. Finally, fill out Section D if any supplementary information is needed. Ensure that any additional comments or details relevant to the claim are clearly documented.
8. Once all sections are completed accurately, you can save your changes. After that, you may download, print, or share the form as needed to proceed with your claim.

Take the next step and complete your Claimant And Employer Statement online today.