Forms (PDF)
Below are the links to printable LTD Plan claims forms. Instructions are included in each document. Please contact your employer with questions on how to complete and submit your claim.
If it appears you will be absent from work longer than the STI coverage period, we ask that you complete and submit the forms around day 60 of the 100 consecutive work day of your STI leave.
A claim can not be processed until the Member Employee Statement, Employer Statement, Initial Attending Physcian Statement, and supporting medical documents are received by the Claims Administrator.
Member Employee Statement
Employer Statement
Employer Statement Supervisor Section Only
Initial Attending Physician Statement
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version.
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