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Pregnancy Disability Form

Pregnancy disability forms are beneficial for women who want to get maternity leave. Working ladies have right to take leave in their gestational period and still get their salary. A sample of such a pregnancy disability form is given below. It is ready to use so feel free to use it for your leaves.

APPLICATION FOR DISABILITY/MATERNITY BENEFITS

Human Resources, ABC Office UK. 443-4042

Pages one and two of this form should be completed by the employee. The employee section may be completed electronically, by typing in the gray areas, which will expand. Pages three and four must be completed by the employee’s physician.

EMPLOYEE INFORMATION (please print)

Full name (Last, First) SUID

 

Address Phone#

 

Date of Birth Male Female

 

List the duties of your occupation at the time of disability:

 

I have been unable to work because of this disability since:

 

(Month/Day/Year)

I returned to work on a part- time basis:

 

(Month/Day/Year)

I returned to work on a full- time basis:

 

(Month/Day/Year)

Date of your accident or date you first noticed the symptoms of your injury/illness:

 

(Month/Day/Year)

Is your injury/illness related to your occupation?

Yes (   )

No  (   )

If yes, explain:
Describe how and where accident occurred or describe the first symptoms of your injury/illness:

 

Date you were first treated for your illness or injury:

 

 

(Month/Day/Year)

Treated by Physician – Name and Address:

Hospital Name and Address

Have you ever had the same or similar condition in the past?

Yes  (   )  No (   )

 

 

(Month/Day/Year)

Treated by Physician – Name and Address:

 

 

 

Hospital Name and Address:

Describe any other income you are receiving or are eligible to receive as a result of your disability:

Source of Income

Amount of Income

Date Income Began

Date Income Ended

       
       
       
       

The above statements are true and complete to the best of my knowledge and belief. I hereby authorize any hospital or physician who has treated me, or person who has attended me or examined me, or any company or government agency, to furnish to Syracuse University or its representative, any and all information with respect to any illness, medical history, consultations, prescriptions, treatments of benefits, and copies of all applicable records. A copy of this form will be as valid as the original.

_____________________________________              _________________________________

Employee Signature                                                                          Date

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