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Short Term Disability Claim |
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Use
You've become disabled (through injury or sickness) and are no longer able to work.
Use the Wage
Indemnity Benefits Claim form to make your claim for Short
Term Disability benefits.
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Information Needed to Complete the Form
Your personal Member information is needed to complete the form.
The policy number must be
included on the form. In addition, information
such as:
- details of the sickness and/or accident,
- your employer's statement and signature,
- the physician's contact information, and
- the attending physician's statement and signature
is also required.
Please follow the instructions on the form. |
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Notes
- Your claim must be filed within 30
days of becoming disabled.
- Both your employer and your doctor must complete their sections
of the form before the claim will be considered.
- The Member must sign on both
pages of the form.
Questions on completing the form should be directed to the Plan
Administrator.
Completed forms should be sent to the Plan
Administrator. |
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Plan Administrator
International Association of Heat and Frost Insulators & Asbestos Workers, No. 118 Health and Welfare Trust Fund
Administrator
c/o D.A. Townley & Associates Ltd.
101 – 4190 Lougheed Highway
Burnaby, BC V5C 6A8
Phone: 604-299-7482 or 1-800-663-1356
Fax: 604-299-8136
Email: Health
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PDF - 27 Kb)