Follow the steps to ensure your claim is completed correctly.

1. Click ‘Get Form’ button to obtain the Proof Of Disability form and open it in your digital editor.
2. Begin with 'Part A - Claimant’s Statement'. Fill in your full name, including your first, middle, and last name, and provide your Social Security number.
3. Enter your current address, including street number, street name, city, state, zip code, and apartment number, if applicable.
4. Indicate your telephone number and your age. Next, specify your marital status by selecting 'Yes' or 'No' for the married question.
5. In the disability section, describe your condition, including any relevant details about how, when, and where the injury or illness occurred.
6. Specify the date you became disabled by providing the month, day, and year. Indicate if you worked on that day and whether you have since earned any wages.
7. List your last employer’s name along with their address and telephone number, and detail your employment dates and average weekly wages.
8. Complete the questions regarding any current benefits you may be receiving, including wages, workers' compensation, unemployment insurance, personal injury claims, or long-term disability benefits.
9. If applicable, provide details about any previous disability benefits you received within the last 52 weeks. Ensure you check all relevant boxes and fill out accompanying information.
10. Read the instructions above before signing the form. If you are unable to sign it yourself, your representative may sign on your behalf, and their relationship to you should be noted.
11. After completing Part A, ensure your health care provider fills out Part B. No claim should be mailed until this is completed and signed.
12. Lastly, save your changes, and download or print your completed form for your records before submitting it to your last employer or their insurance provider within thirty days of becoming disabled.

Take the next step towards receiving your benefits by completing your Proof Of Disability claim online today.