Disability Benefits Claim Form

Complete this form within 30 days of the date your physician disables you. Ask your physician to complete the Doctor's Statement on the back of the form. Then ask the human resources or payroll department at your place of employment to complete and return this same form to the Benefits Fund.

Request for Accident Details Form

If your injury could be the result of someone else's negligence and/or a motor vehicle accident, complete this form and submit it to the Fund Office with the Disability Benefits Claim Form. 

Attending Physician's Statement of Functionality Form

Ask your physician to complete this form, which provides medical evidence to support an extension of disability benefits. Ask your doctor to return this form to the Fund office as soon as possible.

Attending Physician's Statement of Continued Disability for Mental Health

Authorization to Obtain and Release information
Sign and date this form and return it with your Notice and Proof of Claim for Disability Benefits form. By completing this form, you authorize the NYSNA Benefits Fund and The Hartford Life Insurance Company to contact your provider for information needed to evaluate and administer your benefits claim.