Get Uebt Sick Leave/disability Extension Form - Ufcw And Employers ...

Filling out the UEBT Sick Leave/Disability Extension Form online is an essential process for employees seeking to claim benefits during a period of disability. This guide will help you navigate through the form smoothly and accurately, ensuring that all necessary information is provided.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen document editor.
2. Begin with Part 1, where you will select one option: Sick Leave Only, Disability Extension Only, or Sick Leave and Disability Extension. This helps specify the type of claim you are making.
3. In Section 1-A, fill in your last name, first name, initial, mailing address, date of birth, social security number, home phone number, city, state, and zip code. Make sure to check if this address represents a change and provide the date of the change, if applicable.
4. In Section 1-B, note the first date you were absent due to your disability and your expected return-to-work date. Additionally, indicate whether you were injured on the job by answering yes or no and providing the injury date if applicable.
5. Proceed to Section 1-C, where you may fill in your doctor visit details after your employer completes Part 2. Indicate whether you saw a doctor during your disability.
6. In Section 1-D, describe your disability in detail. This information is crucial for processing your claim.
7. Sign and date the form in the employee signature section. Ensure all information is accurate to avoid delays in processing.
8. Part 2 will be completed by your employer. Ensure they fill in details regarding your regularly scheduled work hours, job classification, and any additional relevant information regarding your absence.
9. If applicable, ensure Part 3 (Attending Physician's Statement) is filled out by your physician. This is mandatory for the first day of disability pay and to continue receiving payments beyond the initial week.
10. Once all necessary sections are completed, review the entire form for accuracy. You can then save changes, download, print, or share the completed document as needed.

Start filling out your UEBT Sick Leave/Disability Extension Form online now to ensure you receive the benefits you are entitled to.