This checklist will help you gather the information you may need to complete the Internet Disability Benefits Application and the Disability Report.
DISABILITY APPLICATION
- Dates of marriages and divorces.
- Names and dates of birth of your minor children and your spouse.
- Military Service discharge information (Form DD 214) for all periods of active duty.
- W-2 Form (or your IRS 1040 and Schedules C and SE if self-employed) from last year.
- Checking or savings account number, including the bank’s 9-digit routing number, if you want Direct Deposit for your benefit checks.
DISABILITY REPORT
- Name, address and phone number of someone we can contact who knows about your medical conditions and can help with your claim.
- Names, addresses, phone numbers, patient ID numbers, and dates of treatment for all doctors, hospitals, and clinics.
Note: You may want to refer to any Medical Records you have.
- Names of medicines you are taking and who prescribed them.Note: You may want to have your medicine bottles available.
- Names and dates of medical tests you have had and who sent you for them.
- A list of the jobs (up to 5) that you had in the 15 years before you became unable to work. Include the dates you worked at those jobs, if possible.
- Information about any insurance or workers’ compensation claims you filed, such as claim number and name, address and phone number of insurance company.
We may contact you for additional information after you submit your application and report.
