Disability Claim Form
Insured Member Information
Member Policy Number
Full Name
First Name
Middle Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Employment History
Signature of the Patient/Member
Date Signed
-
Month
-
Day
Year
Date
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Claim Information
Do you have other insurance coverage?
Yes
No
Other Insurance Coverages
Was the disability related to employment?
Yes
No
Disability due to
Accident
Pregnancy
Illness
Other
Please provide specific details of the accident
Please provide specific details of the Illness
If Other, please provide specific details below:
Expected Date of Delivery
-
Month
-
Day
Year
Date
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Hospital/Physician Information
Initial treatment for this disability
-
Month
-
Day
Year
Date
Current date of treatment
-
Month
-
Day
Year
Date
Date when member cannot go to work
-
Month
-
Day
Year
Date
Admission Date (If admitted)
-
Month
-
Day
Year
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
-
Month
-
Day
Year
Date
Was the patient been hospitalized because of this event?
Yes
No
Upload hospital bill, invoice, or receipt
Browse Files
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of
Name of the Hospital
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Name
First Name
Last Name
Physician Contact Number
-
Area Code
Phone Number
Physician Signature
Date Signed
-
Month
-
Day
Year
Date
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Employer Details
Employee Name
First Name
Last Name
Job Position
Date Hired
-
Month
-
Day
Year
Date
Average Hours per week
Rate per hour
Annual Income
Expected Return Date
-
Month
-
Day
Year
Date
Actual Start Date
-
Month
-
Day
Year
Date
Duties and Responsibilities
Rows
Yes
Hours per day
Remarks
Lifting
Yes
No
Pulling/Pushing
Yes
No
Crawling
Yes
No
Sitting
Yes
No
Walking
Yes
No
Climb
Yes
No
Standing
Yes
No
Driving
Yes
No
Employer Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: