Get Short Term Disability Claim Form - Empireblue

Filling out the Short Term Disability Claim Form - EmpireBlue can be a critical step in obtaining the benefits you need during a time of illness or injury. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to access the Short Term Disability Claim Form - EmpireBlue and open it in your preferred editor.
2. Section I should be completed by the employee. Begin by filling in your full name (last, first, M.I.) followed by your gender, birthdate, and contact information, including your primary and alternate phone numbers, email address, and home address.
3. Next, indicate your marital status and social security number. Provide details about the disability, including the reason, specific dates related to your absence from work due to your disability, and if applicable, any work-related injury information.
4. In this section, you will need to sign and date the authorization to release medical information to Anthem Life & Disability Insurance Company.
5. Section II is to be completed by the employer. Make sure your employer provides their information, including group policy number, employment dates, and details related to your job title, hours worked, and wage information.
6. After all relevant sections are completed, ensure that your employer's representative has signed and dated the form.
7. Finally, you can save your changes, download the completed form, print it, or share it as needed. Review the form for completeness before submission.

Start filling out your Short Term Disability Claim Form - EmpireBlue online today to ensure timely processing of your claim.