Patient Disability / Insurance Claim Form

* = required fields
Note: If your form(s) is/are for Pregnancy, please be aware that standard time off is 6 weeks following a vaginal delivery, and 8 weeks following a C-Section. If you are planning on taking more time off – before or after your Delivery – please indicate this on Question 7 and include the reason(s).
5. Reason for claim

6. Who is this form for?

Has this been discussed with your doctor?

10. Will you return from leave on “regular” duties?

11. When this form is completed, which would you like us to do?

Attach the appropriate files (if applicable)
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