CLAIM FORMS

Instructions for printing these forms.

	Using your mouse highlight the text to be printed.
	Click on FILE in the menu bar.
	Click on PRINT.
	In the Page Range Box check the selection box.
	Click on PRINT and you are done.

*** This Section For *** Physician’s Statement

S.P. & S. Use only! (** No Claim will be paid without a Physician’s Statement! ** )

No._____________ Claimant’s Name: ________________________________________________________________

Name_____________________ Diagnosis (illness or injury) _________________________________________________________

Disabled from______ to_______ _______________________________________________________________________________

Day’s ______________________ Was any operation performed? ________ If so, what? ____________________________________

Date of Previous Claim________ _______________________________________________________________________________

Date Paid __________________ Claimant’s condition at last visit? _____________________________________________________

Check Number______________ Please state below dates claimant unable to work at their occupation.

Class ______________________ From ________________________ to _____________________

Amount Paid ________________

Unpaid dues withheld __________ Physician Signature ____________________________________________ Date______________

Mail Claims to:

Mike Cousineau Address: _________________________________________________________________________

452 NE Laura Ave

Gresham, OR 97030 City; State; Zip: ___________________________________________________________________

Phone number: ________________________________________________________

Statement of Claimant as to Disability

** Complete all questions fully, otherwise payment will be delayed or declined. **

Print Full Name: ___________________________________ Age: ________________

Date which you became disabled? ________________________________________________________

Last date you worked prior to illness or injury, or is it the same date? ____________________________

Occupation: _____________________________________________ Date of Birth: _________________

What was the nature of your disability or illness? (Give full details): ______________________________

_____________________________________________________________________________________

Have you ever had the same kind of illness? _____________________ When? ______________________

State dates you were treated by a physician: __________________________________________________

Have you applied for a medical retirement? ______________________ When? ______________________

Have you received a medical retirement or voluntary separation from employment?

Yes/No _____________________ If yes, When? __________________________

Give date you returned to work, or state "Still Disabled." ________________________________________

I, the undersigned, do hereby warrant the foregoing answers and statements to be correct and true, without evasion or reservation, and I agree that if any are found to be untrue, all rights under the By-Laws of the Association shall be void.

** Date ________________________________

** Claimant’s Signature ____________________________________________________

** Address: ______________________________________________________________

** City, State, Zip _________________________________________________________

** Phone number _________________________________________________________