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Long-term disability claim forms and instructions

 

Step 1

Please complete the following forms and return to Human Resources. You may either mail, fax, or, bring them to Human Resources.

1. Employee's statement
2. Other income questionnaire
   

List any income you will be receiving while on LTD. Do not include income from a spouse for example. Please sign and date in all three spaces.

Step 2

Please have your physician complete:

Attending physician's statement
and mail completed form directly to:
Matrix Absence Management, Inc.
7 Skyline Drive
Suite 275
Hawthorne, NY 10532

Step 3

Print and keep for your records:

Tax information

Should you have any questions or concerns, please contact Human Resources. Thank you.