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Customer Service: Frequent Ask Question

Submit a Disability Claim Online
Please provide as much information as possible. To go back to a previous page, click your browser's "Back" button. If the information you entered does not display, click your browser's "Refresh" or "Reload" button. Be sure to click the "Continue" button at the bottom of each page to save your information.

In Step 6, you'll be able to review and print all the information you've provided. A Case Manager may call you to confirm the information you've provided or to request additional information.

Step 1 of 6
* Indicates required field.

Sender Information
*Are you the: Employee Employer Other
*First Name: *Last Name:
*Phone: . . Email:

Claimant (Employee) Information
*First Name: *Last Name:
Security Number:
-- Date of Birth://
 mm /  dd  / yyyy
Address 1:
Address 2:
City: State: Zip:
Phone: . . Email:
Gender: Female Male Marital Status:   

Employer Information
Work Location
Address 1:
Work Location
Address 2:
City: State: Zip:
Supervisor First Name:Supervisor Last Name:
Supervisor Phone: . . Supervisor Email: