Get Member's Statement For Occupational Disability

Filling out the Member's Statement For Occupational Disability can seem daunting, but this guide will help you navigate each step with confidence. By following these clear instructions, you can ensure that your form is completed accurately and efficiently, helping you receive the benefits you need.

Follow the steps to successfully complete your form online.

1. Select the ‘Get Form’ button to acquire the Member's Statement For Occupational Disability, and open it in your preferred editor.
2. Begin by entering your personal information in the Member Information section. This includes your full name (first, middle, last), Social Security number, mailing address, daytime phone number, city, state, and zip code. Ensure you use only black ink or type the information.
3. In the Disability Information section, describe your present disability comprehensively, including its causes and a complete history. If more space is needed, attach additional pages.
4. Fill out the date of your injury or the beginning of the illness leading to your disability, as well as the date you left your job due to the disability.
5. Indicate the employing city and department where you were working at the time of the disability.
6. Answer whether the information provided in the attached City Statement for Occupational Disability is accurate. If not, note any discrepancies.
7. Identify which duties listed in the City Statement you believe you cannot perform due to your disability.
8. Comment on the status of your condition—state if it is worsening, stable, or improving, and provide an explanation.
9. List all physicians who have treated you during your present disability, including their names, addresses, and dates of attendance.
10. Indicate whether you have received treatment at a hospital or clinic since your disability began. If yes, provide the institution names and treatment dates.
11. In the Member Certification section, read the statements carefully, sign your name, and enter the date you are signing the document.
12. Finally, review the completed form for accuracy. You can save your changes, download, print, or share the form as needed.

Start the process of filing your documents online today!