Tip for Insurer-specific

Describe your WORST days, not your best — SSA needs to understand your limitations

Tip for Insurer-specific

Be specific about what you struggle with: 'I need help buttoning shirts' vs 'I have trouble dressing'

Tip for Insurer-specific

If a family member or friend helps you daily, have them complete a third-party ADL form to corroborate

Social Security Disabilitymoderate

Activities of Daily Living (ADL) Form

Insurer-specific · Disability Insurance Carriers

Detailed report of daily activities, sleep patterns, social interactions, household tasks, driving, and any physical or cognitive limitations experienced throughout the day.

Form Details

Total fields: 50
Auto-fillable: 20 (40%)
Time without BeneFill: 45 minutes
Time with BeneFill: 12 minutes
Time saved: 33 minutes
Filled by: patient
Frequency: per incident

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Where to Submit This Form

📬

Return to the requesting agency (SSA, insurer, or attorney)

Complete and return to whoever sent the form.

Filing Deadline

Typically within 30 days of receipt from SSA or the insurer.

Required Attachments

📎 Completed questionnaire describing your daily activities and limitations
📎 Third-party ADL form from a family member or caregiver (if requested)

Processing Time

Part of the disability claim evaluation — reviewed within the standard claim timeline.

What Happens Next

The evaluator will use your ADL responses to assess the severity of your functional limitations and how they affect your ability to work.

Tips for This Form

✓ Describe your WORST days, not your best — SSA needs to understand your limitations
✓ Be specific about what you struggle with: 'I need help buttoning shirts' vs 'I have trouble dressing'
✓ If a family member or friend helps you daily, have them complete a third-party ADL form to corroborate

More Social Security Disability Forms

SSDI Application

SSA-16-BK · SSA

Application for Social Security Disability Insurance Benefits. Requires detailed work history, earnings record, and medical condition documentation.

SSI Application

SSA-8000-BK · SSA

Application for Supplemental Security Income for aged, blind, and disabled individuals with limited income and resources. Must be completed via SSA interview.

Adult Disability Report

SSA-3368-BK · SSA

The most complex patient-facing disability form. 15 pages requiring complete medical history, all diagnoses, medications, treating providers, hospitalizations, and work history.

Work History Report

SSA-3369-BK · SSA

10-page report requiring detailed descriptions of all jobs held in the past 15 years including physical demands, tools used, supervision, and lifting requirements.

Function Report

SSA-3373-BK · SSA

10-page functional assessment covering ADL capacity, daily routines, social functioning, cognitive abilities, and physical limitations.

Authorization to Disclose Information

SSA-827 · SSA

Authorization allowing SSA to collect medical and other information from providers, hospitals, and other sources for disability determination.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Disability Insurance Carriers or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.