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  Temporary Total Disability
Information Required:
1. Proof of Temporary Total Disability Claims Form
• Medical Examiner’s Report
• Declaration of Health Form
The above forms are to be used in the event that you are temporarily totally disabled from your occupation as a result of injury or sickness.
Please refer to the instructions below in completing the three sections of the form:
Employers Statement
This section of the form must be completed by an authorized representative of your company. They must also provide the documentation listed in the left hand margin of the claim form:
• Photocopy of Enrollment card or other proof of enrollment
• Verification of premium deduction
Claimant’s Statement
The person claiming benefits must complete this section, providing details of accident or sickness. If the person claiming is medically unfit to complete this section it can be filled out by a family member. Please attach the documentation listed in the left hand margin:
• Completed Attending Physician’s Statement
• Copy of newspaper clipping or police report, if applicable
Authorization To Obtain Information
The claimant is required to sign this in order that we may obtain information required to process his/her claim.
Claim should be submitted to the address indicated on the top left hand side of the claim form. |
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