Get Group Short-term Disability Statement Of Employee - Lackawanna

Filling out the Group Short-Term Disability Statement of Employee - Lackawanna is crucial for processing your disability claim. This guide will walk you through each section of the form, helping you provide the necessary information accurately and efficiently.

Follow the steps to successfully complete your disability statement online.

1. Click the 'Get Form' button to access the document and open it in your preferred online editor.
2. Begin with your full name, including your last name, first name, and middle initial in the designated fields. This ensures the claim is properly attributed to you.
3. Input your Social Security Number in the appropriate field to verify your identity and eligibility.
4. Provide your street address along with your mailing address for correspondence regarding your claim.
5. Enter your phone number, including the area code, so that the processing team can reach you if needed.
6. Fill in your city, state, and zip code to clarify your location.
7. Include your email address and indicate if you would like to be contacted via email.
8. Document your date of birth, the date you last worked, and whether you were hospitalized due to your condition, including the dates of confinement if applicable.
9. Specify your gender and provide the date of your disability, also indicating if it is due to a sickness or injury.
10. In the section provided, describe the nature of your sickness or the circumstances of your injury.
11. Indicate your height and weight to provide additional personal information required for your claim.
12. If you have returned to work partially or fully, indicate those dates, if relevant.
13. State whether your disability is due to your occupation and if you intend to file for Workers' Compensation.
14. Provide details of any medical treatment received and the names and addresses of your doctors on a separate page.
15. You must decide if you want federal income taxes withheld from your benefits and specify the amount, if applicable.
16. Detail any other forms of income that you are receiving or have applied for, including social security or workers' compensation.
17. Review the statement of truth at the bottom, ensuring that all statements are complete and accurate before signing and dating your submission.
18. Select your preferred payment method, complete the banking information for direct deposit, and confirm the accuracy of the details.
19. Once everything is completed, save the changes, and download a copy of your form. You can also print it or share it as needed.

Start filling out your Group Short-Term Disability Statement of Employee - Lackawanna online today for efficient processing.