Health Benefit Forms

Long Term Disability

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.

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.

You must also complete the patient’s section of the Attending Physician’s Initial LTD Benefits Statement and forward to your doctor for completion.

Completed forms should be forwarded to the Plan Administrator.

More Information

Questions on completing the form should be directed to the Plan Administrator.

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