Get 859 455 8650

Filling out the 859 455 8650 form properly is essential for ensuring your disability claim is processed smoothly. This guide provides a user-friendly walkthrough to help you complete each section with clarity and confidence.

Follow the steps to successfully complete the 859 455 8650 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with filling in the 'Employer Information' section. Include the employer's name, control number, and complete address, including the ZIP code.
3. In the 'Claim Information' section, specify if your absence is work-related. If applicable, provide details about any accident that led to your claim. Describe the nature of your illness or injury, including how, when, and where it occurred, and provide your expected return-to-work date.
4. Proceed to the 'Federal Income Tax Withholding Information.' Here, you can choose to request voluntary withholding from your disability payments. Indicate either a percentage or a specific dollar amount you would like withheld from each weekly payment.
5. If your state requires additional tax withholding, fill out the 'State Income Tax Withholding Information' section with either a percentage or a dollar amount.
6. In the 'Release' section, read through to understand the authorization for sharing your health information. You will need to sign and date this section.
7. Next, review the 'Misrepresentation' warning. This section highlights the consequences of providing false information. Acknowledge this by signing and dating under 'Employee's Signature.'
8. Lastly, ensure you have your physician complete the 'Attending Physician’s Statement' as needed, which includes their signature and information about your condition.
9. After completing all sections, review your form for accuracy. You can then save your changes, download, print, or share the form as required.

Complete your documents online with confidence today!