Weekly Indemnity Claim Form

You’ve become disabled (through injury or sickness) and are no longer able to work. Use the Weekly Indemnity Benefits Claim form to make your claim for Weekly Indemnity benefits.

Information Needed to Complete the Form
Your personal Member information is needed to complete the form. Additional information is also required, such as:

• policy number,
• details of the sickness and/or accident,
• your employer’s statement and signature,
• the physician’s contact information, and
• the attending physician’s statement and signature.

Please follow the instructions on the form.

Notes

• Your claim must be filed within 30 days of becoming disabled.
• Both your employer and your doctor must complete their sections of the form before the claim will be considered.
• The Member must sign on both pages of the form.

Completed forms should be sent to the Plan Administrator.

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