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United Food and Commercial Workers Unions and Employers Midwest Health Benefits Fund 9801 West Higgins Road Suite 500 Rosemont IL 60018-4740 847-384-7000 800-621-5133 Customer Service FAX 847-384-0196 ufcwmidwest. NAME AND ADDRESS OF ANY NON-UFCW COMPANY WHERE YOU ARE ALSO EMPLOYED 5. FULL NAME OF PATIENT RELATIONSHIP TO EMPLOYEE-MEMBER 6. Attending Physician s Statement for Disability Claim 2. DIAGNOSIS AND CONCURRENT CONDITIONS if Diagnosis Code other than ICDA used please give name 3....
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