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POLICY INFORMATION
EMPLOYER’S NAME
*
IF YOU HAVE ALL THE EMPLOYERS INFORMATION
Yes
No
EMPLOYEE’S NAME
*
NAME / DBA
PHYSICAL ADDRESS
*
CITY
*
STATE
*
ZIP CODE
*
PHONE NUMBER
*
ALTERNATE CONTACT NUMBER
EMAIL
*
GENDER
Male
Female
D.O.B
DRIVER LICENSE NUMBER
*
SSN
*
LEAVE / DISABILITY DATE
*
LAST DATE WORKED
*
HAVE WORKED ANY FULL OR PARTIAL TIME HOURS SINCE YOUR DISABILITY?
Yes
No
LOSS INFORMATION / LEAVE TYPE
TYPE OF LOSS
Work Related Injury
For My own illness or injury
Pregnancy
Family Leave
To Care for a family member who is ill or injured
Family bonding: Newborn, foster child, stepchild, or adopted child
Other
LOSS DESCRIPTION
*
LEAVE / DISABILITY DATE
*
DATE YOU RECOVERED OR RETURNED TO WORK?
*
STATE DISABILITY CASE NUMBER
STATE
CASE NUMBER
DOCTOR’S INFORMATION
NAME
PHYSICAL ADDRESS
CITY
STATE
ZIP CODE
CONTACT PERSON / SUPERVISOR
PHONE NUMBER
ALTERNATE COTACT NUMBER
EMAIL
