Disability Benefits Claim Form
Please ensure all sections of the form are filled out completely and legibly. Submit the completed form to the HR Department of [Your Company Name] within 30 days of the disability incident.
Employment Details |
Full Name: | [Employee Name] |
Employee ID: | |
Position Title: | |
Department: | |
Date of Birth: | |
Phone Number: | |
Email Address: | |
Disability Information |
Date of Injury: | January 06, 2052 |
Location of Injury: | |
Type of Disability: | |
Incident Details: | |
Expected Duration: | |
Medical Details |
Physician’s Name: | [Name] |
Facility Name: | |
Address of Facility: | |
Date of Treatment: | |
Attach copies of all relevant medical reports, bills, and any other relevant documentation.
Declaration:
I, [Employee Name], hereby declare that the above information is true and accurate to the best of my knowledge. I understand that any false or misleading information can lead to the denial of my claim or legal actions against me.
Signature: [Employee Name] Date: April 16, 2052
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