Get Ufcw & Employers Trust Sick Leave Claim Form/disability Extension Application 2019-2025

Completing the UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application is essential for ensuring that your claims are processed accurately and efficiently. This guide provides clear, step-by-step instructions to help you navigate the form with confidence.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the Sick Leave Claim Form/Disability Extension Application. Ensure you have a reliable internet connection for a smooth process.
2. Begin with the Employee Section (Part 1). Here, you will enter your personal contact information. Check one of the boxes at the top to indicate whether you are applying for Sick Leave only, Disability Extension only, or both.
3. Fill in the Employee Personal Contact Information. Include your last name, first name, middle initial, date of birth, member ID or last four digits of your Social Security number, and your mailing address. Ensure to note if there is an address change.
4. In the Dates of Illness, Injury, or Disability section, enter your last day worked and the first date absent. These dates must match the information provided in your employer's section.
5. For the Illness, Injury, or Disability Information, confirm that the illness is your own and provide any relevant details, including if it’s job-related. Attach any necessary documentation from your physician if applicable.
6. Sign and date the form in the Employee Signature section. This confirms your request for benefits and acknowledges the provided information is accurate.
7. After you complete Part 1, submit the form to your employer so they can fill out the Employer Section (Part 2). Inform them to complete their section accurately and sign it after you have returned to work or after your first absence.
8. In the Employer Section, ensure that your employer checks the correct work schedule and fills in the first week’s working hours accurately.
9. Once both sections are complete and signed, submit the form as directed. Remember to keep a copy for your records.
10. Finally, you may save changes, download, print, or share the completed form as needed.

Start filling out your UFCW & Employers Trust Sick Leave Claim Form/Disability Extension Application online today for a seamless claims process.