Long Term Disability Claim

Use the Statement of Claimant for Long Term Disability Benefits if you’ve been disabled (through sickness or injury) for at least 26 weeks and are now wishing to apply for LTD benefits.

Please contact the Plan Administrator for a copy of this form.

Your personal Member information is needed to complete the form. The Plan number (70682) must be included on the form. In addition, information such as:

• details of the sickness and/or accident,
• the physician’s contact information,
• details of your current condition,
• information on other benefits to which you may be entitled, and
• the signature of a witness is also required.

Please follow the instructions on the form.

Once you have applied for LTD Benefits, you may be required to complete the Attending Physician’s Initial LTD Benefits Statement before your LTD claim can be approved.

You must complete the patient’s section of the Attending Physician’s Initial LTD Benefits Statement and forward to your doctor for completion.

Please contact the Plan Administrator for a copy of this form.

Your name and signature is needed to complete the form. In addition, your doctor must provide detailed medical information related to your current condition and sign the form.

Questions on completing the forms should be directed to the Plan Administrator.

Completed forms should be forwarded to the Plan Administrator.