Get Ufcw & Employers Trust Sick Leave Claim Form/disability Extension Application 2017-2025

Filling out the UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application online can streamline your claims process and ensure you receive the benefits you need. This guide will provide you with a clear understanding of how to properly complete each section of the form to maximize your chances of a successful claim.

Follow the steps to complete your application accurately.

1. Click 'Get Form' button to access the UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application and open it for editing.
2. Fill out Part 1, which requires employee information. Input your home phone number, last name, first name, middle initial, date of birth, and social security number. Provide your mailing address, including city, state, and zip code. If your address has changed, check the box and indicate the date of the change.
3. In section 1-B, enter the first date you were absent due to your disability and the expected return-to-work date. Indicate whether you were injured on the job by checking the appropriate box. If applicable, fill in the injury date in section 1-C.
4. If you visited a doctor during your disability, indicate this in section 1-D and provide details about your disability. Confirm that you are requesting either Sick Leave payments or Disability Extensions for the days lost due to disability. Sign and date the form.
5. Once you complete Part 1, pass the form to your employer to fill out Part 2. Ensure they complete all necessary sections, including the employee's regularly scheduled work hours and the first day of absence.
6. In section 2-A, your employer needs to provide their identified work schedule, hourly rate, and job classification. They should also indicate any hours or days worked during the claim period.
7. In section 2-B, if applicable, your employer should indicate if you worked on the first day of paid disability or returned to work during the claim period, providing relevant dates and hours.
8. Upon completion of both parts, your employer will sign and provide necessary details in section 2-C to verify the information is accurate. Ensure they also provide their contact phone number.
9. In Part 3, unless already completed, arrange for your physician to fill out the required details regarding your disability. This includes diagnosis and treatment dates. Their signature is necessary for your claim.
10. After all sections are accurately completed, save your changes and decide whether to download, print, or share the form for submission.

Complete and submit your forms online to ensure timely processing of your claim.