D.A. Townley  -  Plan Administrators Iron Workers Union Local 97 International Association of Bridge, Structural, Ornamental and Reinforcing Iron Workers 
 

health
benefits

        
 
 
 
 
 
 
 
 
 
 
 
 
   
        
   
 
 
 
 
   
 
 
 
 
   
 

Long Term Disability Claim

Use
Use the Statement of Claimant for Long Term Disability Benefits if you've been disabled (through sickness or injury) for at least 26 weeks and are now wishing to apply for LTD benefits.


Information Needed to Complete the Form
Your personal Member information is needed to complete the form. The Plan number (70682) must be included on the form. In addition, information such as:

  • details of the sickness and/or accident,
  • the physician's contact information,
  • details of your current condition,
  • information on other benefits to which you may be entitled, and
  • the signature of a witness is also required.
Please follow the instructions on the form.


Notes
You must also complete the patient's section of the Attending Physician's Initial LTD Benefits Statement and forward to your doctor for completion.

Questions on completing the form should be directed to the Plan Administrator.

Completed forms should be forwarded to the Plan Administrator.



 

Form Link
 

Related Links
Long Term Disability Benefit Information
Attending Physician's Initial LTD Benefit Statement
Statement of Employer Regarding Employee Group Long Term Disability Claim
Application for Disability Credits
 
© 2000-2008 D.A. Townley All rights reserved.