Weekly Indemnity Claim
Information Needed to Complete the Form
Your personal Member information is needed to complete the form. In addition, information such as:
- details of the sickness and/or accident,
- an authorized union signature,
- details of any other disability benefits to which you are entitled, and
- the attending physician’s statement and signature is also required
Please follow the instructions on the form.
- Your claim must be filed within 30 days of becoming disabled.
- Both your union and your doctor must complete their sections of the form before the claim will be considered.
- The Member must sign on both pages of the form.
Questions on completing the form should be directed to the Plan Administrator.
Completed forms should be forwarded to the Plan Administrator.