National Roofers Union & Employers Joint Health & Welfare Fund
DISABILITY CLAIM - SUPPLEMENTARY
This form MUST be completed on or about: _______________________
1. Personal Information
Your Name: _________________________________________________
Social Security Number: _______________________________________
Date of Birth:________________________________________________
Address:____________________________________________________
____________________________________________________
3. State last day worked because of disability:
__________ / __________ / __________
month day year
5. If injured, how and where did the accident occur?
7. Have you or do you intend to le this claim under Workmen’s
Compensation?
q Yes q No
9. Diagnosis and concurrent conditions:
10. Frequency of visits:
q Weekly q Monthly q Other:________________________________
12. Is patient totally disabled from his/her regular occupation?
q Yes q No
Date patient became totally disabled: ______ /_______ /______
month day year
14. Attending Physician’s Information:
Physician’s Name: ____________________________________________
Physician’s Signature:_________________________________________
Degree:_____________________ Date:__________________________
Address:____________________________________________________
____________________________________________________
2. Authorization to release information:
I hereby authorize the undersigned physician to release any information
acquired in the course of my examination or treatment. I also make claim for
benets and certify that the statements under Part A are true and complete to
the best of my knowledge.
________________________________________ ________________
Signature of Insured Date
4. On what date were or will you be able to perform full-time work:
__________ / __________ / __________
month day year
6. Did injury occur in the course of employment?
q Yes q No
8. Are you now engaged in the duties of any occupation or endeavor for
wages, prots or compensation?
q Yes q No
11. Is patient totally disabled from any occupation?
q Yes q No
Date patient became totally disabled: ______ /_______ /______
month day year
13. On what date will the patient be able to resume normal activities and
return to work?
__________ / __________ / __________
month day year
15. Remarks:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
PART B: ATTENDING PHYSICIAN’S STATEMENT
Return completed forms to:
National Roofers Union & Employers Joint Health & Wefare Fund, Attn: Claims Department, 3001 Metro Drive – Suite 500, Bloomington, MN 55425
Phone:
(952) 854-0795
, Toll Free: (800) 622-8780, Fax:
(952) 854-1632
Group Number: F61
To be completed and signed by the Employer to sign off on last day of work.
Date of last day of workEmployer Signature Signed
PART A: TO BE COMPLETED BY PATIENT (INSURED)
