LY Your application for benefits consists of four forms. Every space on these forms should be filled in to avoid delay in processing your application. If a section does not apply, or information is not available, “NA” should be written in the space so that we know you did not overlook that particular question. If a form is received incomplete, it may be returned for completion. The four forms are: 1. The Employee’s Statement ● ● ● ● 2. Answer every question completely. Be sure.
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How to fill out the SI 11268 online
The SI 11268 form, known as the Employee's Statement for Your Choice Disability Insurance, is an essential document for filing a disability claim. Completing this form accurately and thoroughly is crucial to ensure timely processing of your application.
Follow the steps to successfully complete the SI 11268 online:
- Click the ‘Get Form’ button to access the form and launch it in your chosen editor.
- Begin by entering your personal details in the 'Claimant' section. This includes providing your full name, social security number, address, contact number, birth date, and the name of your partner, if applicable.
- In the 'Employment' section, include your employer’s name, your job title, and a description of your duties. Be sure to fill in the last day you worked and the date you became unable to work due to your disability.
- Describe the cause of your disability accurately, indicating if it was due to an accident, illness, or pregnancy. If it is work-related, state whether you have filed a Workers’ Compensation claim.
- In the 'Sickness/Injury' section, provide a detailed description of your illness or injury, noting when it first occurred and if you had any prior related conditions.
- For the 'Pregnancy' section, if applicable, indicate the expected and actual delivery dates, along with any foreseeable complications.
- List all physicians you have consulted for your condition, making sure to include their specialties, contact information, and the dates of your visits.
- If hospitalized, detail the hospital name, address, and reason for hospitalization in the 'Hospital' section.
- In the 'History' section, list any other relevant illnesses or injuries you have received treatment for in the past five years.
- Document any additional benefits you are applying for or currently receiving in the 'Benefits from Other Sources' section. This includes benefits from Social Security, Workers’ Compensation, and others.
- Finally, read and sign the acknowledgment section to certify that all information provided is accurate to the best of your knowledge. After completing the form, you can save your changes, download, print, or share it as needed.
Complete your SI 11268 paperwork online today for a smoother benefits application process!
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