Long Term Disability Claim – Statement of Employer

The employer completes the Statement of Employer Regarding Employee Group Long Term Disability Claim to provide information to the insurer regarding the Member’s Long Term Disability claim.

Information Needed to Complete the Form
To complete the form the employer must include:

• Information regarding the disabled employee
• Other benefits that the employee may be eligible for
• Any information that may aid in the consideration of the claim.

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