Disability/Workers’ Compensation Request for Application

Member Information

Member Name(Required)

First Last

Member UBC# or Last 4 digits of SSN(Required)

Email(Required)

Enter Email Confirm Email

Primary Phone Number(Required)

Employment Information

Name of Last Employer(Required)

Last Day Worked(Required)

Injury / Illness Information

Are You Reporting an Injury or Illness?(Required)

Date of Injury(Required)

Date of Ilness(Required)

Name of Treating Physician, Hospital, Urgent Care, etc?(Required)

Injury Diagnosis(Required)

Illness Diagnosis(Required)

Have You Filed For or Collected Unemployment?(Required)

Yes

No

Not yet, but will be filing

Injury Information

Where Did the Injury Occur?(Required)

Have You Filed a Workers' Compensation Claim?(Required)

Yes

No

Not yet, but will be filing

Have You Filed a Lawsuit?(Required)

Yes

No

Not yet, but will be filing

Injury Location(Required)

Description of How the Injury Happened(Required)

Paystub Upload

Please upload your paystubs for proof of disability(Required)

Drop files here or

Max. file size: 20 MB.

Alternate Address / Comments

Would you like your Application sent to a different address other than the one on file?(Required)

Yes

No

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Additional Notes or Comments