Disability Benefits Claim Form HR
Disability Benefits Claim Form
Please ensure all sections of the form are filled out completely and legibly. Submit the completed form to the HR Department of [Your Company Name] within 30 days of the disability incident.
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Employment Details |
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Full Name: |
[Employee Name] |
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Employee ID: |
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Position Title: |
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Department: |
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Date of Birth: |
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Phone Number: |
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Email Address: |
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Disability Information |
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Date of Injury: |
January 06, 2052 |
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Location of Injury: |
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Type of Disability: |
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Incident Details: |
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Expected Duration: |
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Medical Details |
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Physician’s Name: |
[Name] |
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Facility Name: |
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Address of Facility: |
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Date of Treatment: |
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Attach copies of all relevant medical reports, bills, and any other relevant documentation.
Declaration:
I, [Employee Name], hereby declare that the above information is true and accurate to the best of my knowledge. I understand that any false or misleading information can lead to the denial of my claim or legal actions against me.
Signature: [Employee Name] Date: April 16, 2052
