Social Security Disabilityhard

Long-Term Disability Claim (Employee Statement)

Insurer-specific · Disability Insurance Carriers

Claimant's statement for long-term disability benefits, typically filed after STD exhaustion (usually 90-180 days). Detailed description of ongoing limitations.

Form Details

Total fields
60
Auto-fillable
40 (67%)
Time without BeneFill
60 minutes
Time with BeneFill
15 minutes
Time saved
45 minutes
Filled by
patient
Frequency
per incident

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Where to Submit This Form

📬

Submit to your long-term disability insurance carrier

File directly with the insurance company administering your LTD policy.

📧

Online portal of your LTD insurance carrier

Most carriers accept claims electronically through their portal.

Filing Deadline

Typically within 90-365 days of disability onset, or within 30 days of STD benefits ending. Check your specific policy.

Required Attachments

  • 📎 Completed claimant statement
  • 📎 Attending physician's statement with diagnosis, prognosis, and functional limitations
  • 📎 Medical records from all treating providers
  • 📎 Employer statement confirming position, salary, and last day worked
  • 📎 Tax returns and W-2s (for income verification)

Processing Time

30-90 days for initial determination. Benefits begin after the elimination period (typically 90-180 days).

What Happens Next

The carrier will review medical evidence and may assign a nurse case manager. You may be required to submit ongoing proof of disability and participate in independent medical examinations.

Tips for This Form

  • ✓ Apply for SSDI simultaneously — most LTD policies offset SSDI benefits, and LTD carriers often require you to apply
  • ✓ Definition of disability often changes at 24 months from 'own occupation' to 'any occupation' — prepare for this transition
  • ✓ Keep copies of EVERYTHING you submit and send all documents via certified mail or keep electronic confirmation

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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