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NAVAJO NATION EMPLOYEE BENEFIT PLAN PRELIMINARY STATEMENT OF DISABILITY-STD P.O. Box 2069 P.O. Box 2069 Cottonwood, AZ 86326 THIS SECTION TO BE COMPLETED BY EMPLOYEE (Please Print) Plan Number 710000

How to fill out preliminary statement of disability

How to fill out a preliminary statement of disability:

1. Begin by gathering all relevant medical documentation and records related to your disability. This may include doctor's reports, test results, and any other supporting evidence.
2. Start the preliminary statement by providing your personal information, such as your full name, address, phone number, and social security number. Make sure to double-check the accuracy of this information.
3. Describe your disability in detail, including the symptoms you experience, the duration of the disability, and any limitations it imposes on your daily activities. Use clear and concise language to explain the impact of the disability on your physical or mental capabilities.
4. Include information about any medical treatments, therapies, or medications you are currently receiving or have received in the past for your disability. This can help establish the severity and ongoing nature of your condition.
5. If you have undergone any surgeries or medical procedures related to your disability, provide the dates and details of these interventions. This information can provide further evidence of the seriousness of your condition.
6. Mention any assistive devices, such as wheelchairs or hearing aids, that you use to manage your disability. These devices can demonstrate the need for ongoing support and accommodation.
7. If your disability affects your ability to work, explain the impact it has on your job performance and any accommodations you require. This information can be useful if you are seeking disability benefits or workplace accommodations.

Who needs a preliminary statement of disability:

1. Individuals who are applying for disability benefits through programs like Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) may need to submit a preliminary statement of disability. This statement helps provide a comprehensive overview of the person's disability and its impact on their daily life.
2. People requesting workplace accommodations due to their disability may also need a preliminary statement of disability. This document can support their request by providing evidence of the nature and extent of their limitations.
3. Individuals involved in personal injury or medical malpractice cases might require a preliminary statement of disability to support their claim and establish the damages caused by the negligent party.

In summary, filling out a preliminary statement of disability involves providing detailed information about your disability, including symptoms, treatments, and its impact on your life. This document may be needed for disability benefits applications, workplace accommodations, and legal claims.

For pdfFiller’s FAQs

What is preliminary statement of disability?

The preliminary statement of disability is a form where an individual reports their initial claim for disability benefits.

Who is required to file preliminary statement of disability?

Individuals who are seeking disability benefits are required to file a preliminary statement of disability.

How to fill out preliminary statement of disability?

To fill out the preliminary statement of disability, individuals must provide detailed information about their disability, medical history, and work experience.

What is the purpose of preliminary statement of disability?

The purpose of the preliminary statement of disability is to assess an individual's eligibility for disability benefits.

What information must be reported on preliminary statement of disability?

Information such as medical records, doctor's diagnosis, treatment received, and impact of the disability on daily activities must be reported on the preliminary statement of disability.

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