Employer Notification

1. Manager/Supervisor

Organization Name:Business Unit:Location:Name:Title:Email:Phone #:Fax #:

2. Human Resources Representative

Name:Title:Email:Phone #:Fax #:

3. Employee Identification

First Name:Last Name:Employee Number:Date of birth (dd/mmm/yyyy):Full address :Home Phone #:Work Phone #:

4. Employee Information

Date of birth (dd/mmm/yyyy):Employee's title:Employee’s work hoursFull-time hours per week:Part-time hours per week:Other:

If the employee works non-standard shifts/cycles, please describe or attach a copy of the shift schedule:

Date last worked (dd/mmm/yyyy):Number of hours worked that day:Next scheduled work day/shift prior to disability (dd/mmm/yyyy):Has the employee returned to work?YesNoIf YES, please provide the date returned to work (dd/mmm/yyyy):Is this employee eligible for STD benefits?YesNo

5. Work Information

Is the current condition due to a work-related accident or illness?YesNoIs it possible that work factors are impacting the employee’s health and/or return to work?YesNoCan't SayIf YES, please provide relevant details:

6. Additional Comments

Please provide any additional claim details or comments:

7. Declaration

I certify that the information in this form, and any further verbal or written statement provided by me in the future, is true and complete to the best of my knowledge. The information in this statement will be kept in disability case file with arc Health and might be accessible by the employee or third parties to whom access has been granted or those authorized by law. By providing the information I consent to such unedited release of any information contained herein.

Authorized Signature:

Date (dd/mmm/yyyy):

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.