• Disability Proof of Claim Form

  • INSTRUCTIONS

    1. Download and print Disability Proof of Claim Form
    2. Complete Section I and either Section II (work related) or Section III (nonwork related)
    3. Have your physician complete Section IV
    4. Upload your completed form and any other supporting documentation
      • If injury is work related, upload copy of worker's compensation award and dates of payments (i.e., check copies)
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