Printable Forms: FNIS Group Insurance, Short Term Disability Claim Forms
The following five forms must be completed, signed and forwarded to First Nations Insurance Services’ office for processing in order to make a claim for Short Term Disability Benefits.
Plan Sponsor’s Statement—Claim for Short Term Disability Benefits
- Plan Sponsor must complete this form, sign and return it to First Nations Insurance Services office for processing.
Short-Term Disability Questionnaire—Physical Job Demands
- Plan Sponsor must complete this form, sign and return it to First Nations Insurance Services office for processing.
Plan Member’s Statement—Claim for Short Term Disability Benefits
- Plan Member must complete this form, sign and return it to First Nations Insurance Services office for processing.
- Plan Member must have their Licensed Physician or Specialist complete the applicable APS, sign and return it to First Nations Insurance Services office for processing.
Short Term Disability Return to Work Notice
- Plan Sponsor must complete this form, sign and return it to First Nations Insurance Services office for processing once employee has returned to work.
