Disability Benefits Claim Refiling Request Form

Disability Benefits Claim Refiling Request Form
Request a review or resubmission of your disability benefits claim after a denial, closure, or correction need.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous Claim Reference Number (if known)
Date of Original Claim Submission
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Refiling Request
Other
Please provide details about your request
Upload any supporting documents (optional)
Cancelof
Should be Empty: