Sec. 125
Disability (Salary Protection) Reliance Standard Claim Form
Posted on Wednesday, November 2, 2005
Disability and Wellness claim form.pdf
Size: 87 KB
For disability claims due accident or illness. This is also the claim form used for Medical Income Benefit.
Form for disability due to accident or illness or for a doctor bill benefit (participant must be disabled for a least one full day and sees a doctor on the day of disability). The form will need to completed by employee, doctor and employer.
Townsite, bldg. no 2, suite105 • 120 SE 6th Ave. •  Topeka, KS 66603-3515  •  (785) 233.4071  •  fax (785) 233.5746