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STD Form for COVID-19
Confirmation of Illness Form
Please only complete this form if your absence is due to symptoms of CO
VID-19 and you're pending
test results, or if you have a clinical diagnosis of COVID-19.
In recognition of the increasing pressure on our medical clinics and hospitals due to the COVID-19 pandemic, we
will not, at the outset, require an Attending Physician’s Statement as part of your disability claim submission if
your absence is due to COVID-19 symptoms, or a clinical diagnosis of the virus. This is a time limited exception
as we move through the current situation.
In the absence of an Attending Physician’s Statement, we require confirmation of your symptoms, your test
results, and any medical treatment you may have received for your condition. Accordingly, please complete
and sign this form and return it with your Employee Package, which you also need to complete.
2. Please indicate the symptoms associated with
Fever Decreased appetite
Cough Runny nose
Muscle aches Vomiting
Sore throat Headache
Shortness of breath
3. Do you
y other health problems that might affect your recovery (e.g. diabetes, heart disease, respiratory
Plan Member Name:
Date symptoms first appeared
day absent from work:
Plan Sponsor Name: