Get Ufcw & Employers Trust Sick Leave Claim Form/disability Extension Application 2022-2025

This guide provides a clear and supportive overview of how to fill out the UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application online. By following these steps, users can ensure that their claims are processed efficiently.

Follow the steps to complete your form accurately.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. In Part 1 - Employee Section, fill out your personal contact information. Check one box at the top to indicate whether this applies to Sick Leave, Disability Extension, or both. Ensure that your name, address, and contact details are complete and legible.
3. In subsection 1-B, provide the dates of your illness, injury, or disability, including the last day worked and the first date absent. Ensure these match the information required in the Employer’s Section.
4. In subsection 1-C, indicate whether the illness, injury, or disability is your own and provide any necessary details, including whether it is connected to a previous claim or if it occurred at the workplace.
5. In subsection 1-D, you must sign and date the form. Your signature indicates your request for Sick Leave benefits or Disability Extensions and confirms the truthfulness of the information provided.
6. In Part 2 - Employer Section, inform your employer that they are required to complete this section. It includes schedule and pay information as well as verification related to your absence.
7. Provide the employer with accurate work schedule information and ensure they sign and date the form. This must occur after you have returned to work or from the first day of absence.
8. In Part 3 - Physician’s Statement, this section must be completed by your physician. They should provide certification regarding your illness or injury, including hospitalization details if applicable.
9. Once all sections are complete, review the form for accuracy. After verifying all the details, you can save changes, download, print, or share the form as necessary.

Complete your applications online today to ensure timely processing of your sick leave and disability claims.