Follow the steps to complete your claim form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the employee section. Provide your name, date of birth, plan number, and social security number as requested in the initial fields.
3. Complete the next fields by providing your address, home telephone number, and marital status. Ensure accurate information for effective communication.
4. Describe your first symptoms of illness or injury in the designated area, and specify the nature of your condition.
5. Enter the dates associated with your illness or injury, including when you first noticed symptoms, when you were treated, and when you became unable to work.
6. Address any relation of the illness or injury to your employment. Indicate whether you have filed a Workers' Compensation Claim.
7. If applicable, provide details about previous similar conditions, including treatment dates and physician information.
8. Discuss your employment status post-illness and indicate your job title and duties prior to your condition.
9. List your family physician along with other medical professionals involved in your treatment for the specific illness or injury.
10. Document any other income you are receiving or are eligible to receive due to your disability, ensuring to attach any relevant award or denial letters.
11. Indicate the amount you want withheld for federal income tax from your long-term disability payments.
12. Review and sign the authorization for the release of your medical information, understanding your rights regarding privacy and access.
13. Finally, ensure all sections are filled in accurately. Save your changes, and prepare to download or print the form for submission.

Complete your Long Term Disability Claims Form online today to initiate your claim process.