Get This Form Should Be Completed On Or After The Initial Date Of Your Disability, Hospitalization

This guide provides a clear and informative approach to completing the form titled 'This Form Should Be Completed On Or After The Initial Date Of Your Disability, Hospitalization' online. Follow the organized steps to ensure that your submission is accurate and efficient, helping to expedite your claim process.

Follow the steps to fill out the disability claim form online.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. In Section A, provide your personal information as the policyholder. Include your first name, middle initial, last name, mailing address, city, state, ZIP code, Social Security number, and phone number. Ensure all details are correct, as inaccuracies may delay processing.
3. Fill out the patient information, including the patient’s first name, middle initial, last name, relationship to the policyholder, sex, and date of birth. Specify the first date of work missed due to the disability.
4. If the disability is due to an accident, describe the accident's details, including the date, where it occurred, and how the incident took place.
5. Complete Section B, the Employer's Statement, which must be filled out, signed, and dated by your employer. This section addresses job-related information, such as the first date of disability, hours worked prior to the disability, and return-to-work status.
6. In Section C, the Physician’s Statement must be completed by the physician or their staff. They will provide diagnosis details, hospitalization dates, and treatment information. Ensure the physician includes their signature, date, and tax ID as required.
7. Once you’ve completed all sections of the form, review it carefully for accuracy. Save any changes made during the online process.
8. Download or print the completed form for your records. You may also need to share it with your employer or physician for their signatures before submitting it.

Complete your documents online today to ensure a smooth and efficient claims process.