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Long Term Disability |
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Use
Use the Statement of Claimant for Long Term Disability Benefits
if you've been disabled (through sickness or injury) and are now wishing to
apply for LTD benefits.
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Information Needed to Complete the Form
Your personal Member information is needed to complete the form.
Your policy number must be included on the form. In addition, information such as:
- details of the sickness and/or accident,
- the physician's contact information,
- details of your current condition,
- information on other benefits to which you may be entitled, and
- the signature of a witness is also required.
Please follow the instructions on the form.
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Notes
You must also complete the patient's section of the Attending Physician's Initial LTD Benefits Statement
and forward to your doctor for completion.
Questions on completing the form should be directed to the Plan
Administrator.
Completed forms should be forwarded to the Plan
Administrator.
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Plan Administrator
D.A. Townley & Associates Ltd.
101 – 4190 Lougheed Highway
Burnaby, BC V5C 6A8
Phone: 604-299-7482 or 1-800-663-1356
Fax: 604-299-8136
Email
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