Tip for Insurer-specific

File the claim as soon as you know you will be out of work — do not wait for the elimination period to pass

Tip for Insurer-specific

Ask your doctor to provide detailed functional limitations, not just a diagnosis

Tip for Insurer-specific

STD typically lasts 13-26 weeks — apply for LTD if your disability will extend beyond that

Social Security Disabilitymoderate

Short-Term Disability Claim (Employee Statement)

Insurer-specific · Disability Insurance Carriers

Claimant's statement initiating a short-term disability claim. Describes disability, symptoms, limitations, daily activities, work history, and treatment.

Form Details

Total fields: 50
Auto-fillable: 35 (70%)
Time without BeneFill: 45 minutes
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Time saved: 33 minutes
Filled by: patient
Frequency: per incident

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Where to Submit This Form

📬

Submit to your employer's HR department or insurance carrier

File with the company or insurer that administers your employer's short-term disability plan.

📧

Email or online portal of your disability insurance carrier

Most carriers have online claims portals.

Filing Deadline

Typically within 30 days of disability onset. Check your policy for exact deadlines.

Required Attachments

📎 Completed employee section of the claim form
📎 Attending physician's statement documenting the disability and expected duration
📎 Employer statement confirming last day worked and job duties

Processing Time

7-14 days for initial claim determination. Benefits typically begin after the elimination period (usually 7-14 days).

What Happens Next

The insurance carrier will review medical documentation and may request additional information from your doctor. If approved, benefits are usually 60-70% of your base salary.

Tips for This Form

✓ File the claim as soon as you know you will be out of work — do not wait for the elimination period to pass
✓ Ask your doctor to provide detailed functional limitations, not just a diagnosis
✓ STD typically lasts 13-26 weeks — apply for LTD if your disability will extend beyond that

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.