You’ve become disabled (through injury or sickness) and are no longer able to work. Use the Weekly Indemnity Benefits Claim form to make your claim for Weekly Indemnity benefits.
Your personal Member information is needed to complete the form. The policy number, 52565 must be included on the form. In addition, information such as:
Please follow the instructions on the form.
Questions on completing the form should be directed to the PLAN ADMINISTRATOR.
Completed forms should be sent to the PLAN ADMINISTRATOR.