Disability Claim Form

Disability Claim Form
Insured Member Information
Member Policy Number
Full Name
First NameMiddle NameLast Name
Age
Date of Birth
MonthDayYear
Date
Email
example@example.com
Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Gender
Employment History
Signature of the Patient/Member
Clear
Date Signed
MonthDayYear
Date

Hospital/Physician Information
Initial treatment for this disability
MonthDayYear
Date
Current date of treatment
MonthDayYear
Date
Date when member cannot go to work
MonthDayYear
Date
Admission Date (If admitted)
MonthDayYear
Date
Diagnosis
Will the patient able to return to work?
Yes (Please fill up the Return Date below)No (Unable to return to work due to permanent disability)
Expected Return Date
MonthDayYear
Date
Was the patient been hospitalized because of this event?
YesNo
Upload hospital bill, invoice, or receipt
Browse Files
Cancelof
Name of the Hospital
Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Physician Name
First NameLast Name
Physician Contact Number
Area CodePhone Number
Physician Signature
Clear
Date Signed
MonthDayYear
Date

Insured Member Information