Long Term Disability Claim

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

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

Completed forms should be forwarded to the Plan Administrator.

Plan Administration Office

45 McIntosh Drive
Markham, ON L3R 8C7

Phone 1-800-263-3564
Fax 905-946-9700
Email: questions@millworkersuniforbenefits.org