Continuing Disability Claim Form

Continuing Disability Claim Form
Please complete this form to update your ongoing disability claim. Accurate and current information is required to continue benefit eligibility.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Claim or Reference Number
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Has your disability or medical condition changed since your last claim?
Other (please specify)
Please describe any changes in your condition or daily activities.
Current treating physician or healthcare provider (name and contact info)
Are you currently receiving any new treatments or medications?
If yes, please list your current treatments or medications.
Have you worked or received any income since your last claim update?
If yes, please provide employer name, dates, and type of work or income received.
Upload supporting medical documents (optional)
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