Get Ufcw & Employers Trust Sick Leave Claim Form/disability Extension Application 2021-2025

The UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application is essential for users seeking to claim sick leave or request a disability extension. This guide will walk you through the process of completing the form accurately and submitting it online to ensure prompt processing.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application and open it in your preferred tool.
2. Fill out Part 1 – Employee Section. Provide your personal contact information, including your last name, first name, middle initial, date of birth, member ID or the last four digits of your social security number, home and cell phone numbers, and mailing address. Check the box if there is an address change. Ensure all fields are completed and legible.
3. In the Dates of Illness, Injury, or Disability section, input the last day worked before absence and first date absent due to your own illness, injury, or disability. Match this information with the Employer's section.
4. Complete the Illness, Injury, or Disability Information section by confirming that the illness, injury, or disability is your own. If it is related to a previous claim within the last 60 calendar days, indicate this by checking the appropriate box and provide any required details.
5. Provide your signature and date in Part 1-D, certifying that the information provided is accurate and for your own illness or injury.
6. Part 2 must be filled out by your employer. Ensure they complete the Schedule and Pay Information accurately, including regular work hours and needed signatures.
7. If required, ensure your physician completes Part 3. The physician must confirm your condition and sign with their information. This part is necessary especially for continuous disabilities.
8. Review all sections for completeness and accuracy. Make any necessary changes before finalizing.
9. After confirming that all required sections are accurately filled, save your changes. You may now download, print, or submit the form directly online.

Begin your claim today by filling out the UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application online.