Short Term Disability Form

Short term disability form is a kind of insurance that compensates a percentage of any employee’s wages for a small duration of time, if they are sick or injured, and cannot do the duties of the job. Coverage generally starts from one to 20 days later your employee undergoes a condition that makes them unable to labour.

Sample Short Term Disability Form

Employee Information

First name ___________________ Last name _____________

Identification number __________________ Date of birth_______________

Permanent address _______________ Province _________________

Gender – Male / Female

City______________ Phone number __________________ State __________________

Date of getting hired ______________________ No of years of service _________________

Hours of work put in weekly _______________ Status – Full / Part time

Disability information

Date of accident ________________Kind of disability ___________________

Hospital name ________________________ Name of physician ______________

Medicines and Treatment prescribed____________________________

Kind of leave needed __________________

Date of beginning of leave __________________

Tentative number of leave days needed _____________________

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