Application for short term disability income benefits

You can help by being ready to:

• Provide any needed documents; and
• Answer the questions listed below.

Documents you may need to provide

We may ask you to provide documents to show that you are eligible, such as:

• Birth certificate or other proof of birth;
• Proof of U.S. citizenship or lawful alien status if you were not born in the United States;
• U.S. military discharge paper(s) if you had military service before 1968;
• W-2 forms(s) and/or self-employment tax returns for last year;
• An Adult Disability Report that collects more details about your illnesses, injuries or conditions, and your work history;
• Medical evidence already in your possession. This includes medical records, doctors' reports, and recent test results; and
• Award letters, pay stubs, settlement agreements or other proof of any temporary or permanent workers' compensation-type benefits you received [more info] .

Important

We accept photocopies of W-2 forms, self-employment tax returns or medical documents, but we must see the original of most other documents, such as your birth certificate. (We will return them to you.)

Do not delay applying for benefits because you do not have all the documents. We will help you get them.

What we will ask you

• Your name, gender and Social Security number;
• Your name at birth (if different);
• Your date of birth and place of birth (State or foreign country);
• Whether a public or religious record was made of your birth before age 5;
• Your citizenship status;
• Whether you or anyone else has ever filed for Social Security benefits, Medicare or Supplemental Security Income on your behalf (if so, we will also ask for information on whose Social Security record you applied);
• Whether you have used any other Social Security number;
• Whether you were ever in the active military service before 1968 and, if so, the dates of service and whether you have ever been eligible to receive a monthly benefit from a military or Federal civilian agency;
• Whether you or your spouse have ever worked for the railroad industry;
• Whether you have earned Social Security credits under another country's Social Security system;
• Whether you qualified for or expect to receive a pension or annuity based on your own employment with the Federal government of the United States or one of its States or local subdivisions;
• Whether you are currently married and, if so, your spouse's name, date of birth (or age) and Social Security number (if known);
• The names, dates of birth (or age) and Social Security numbers (if known) of any former spouses;
• The dates and places of each of your marriages and, for marriages that have ended, how and when they ended;
• The names of any unmarried children under age 18, age 18-19 and in elementary or secondary school, or disabled before age 22;
• Whether you have or had a child under age 3 living with you during a calendar year when you had no earnings;
• Whether you have a parent who was dependent on you for 1/2 of his or her support at the time you became disabled;
• Whether you had earnings in all years since 1978;
• The name(s) of your employer(s) or information about your self-employment and the amount of your earnings for this year and last year;
• Whether you received or expect to receive any money from an employer since the date you became unable to work;
• Whether you have any unsatisfied felony or arrest warrants for escape from custody, flight to avoid prosecution or confinement, or flight-escape;
• The date you became unable to work because of illnesses, injuries or conditions and if you are still unable to work; and
• Information about any workers' compensation, black lung, and/or similar benefits you filed, or intend to file for. These benefits can:
  • Be temporary or permanent in nature;
  • Include annuities and lump sum payments that you received in the past; and
  • Be paid by your employer or your employer's insurance carrier, private agencies, or Federal, State or other government or public agencies.
  • Workers' Compensation
  • Black Lung Benefits
  • Longshore and Harbor Workers' Compensation
  • Civil Service Retirement
  • Federal Employees' Retirement
  • Federal Employees' Compensation
  • State Disability Insurance benefits
  • Military retirement pensions based on disability

  Note

  You also should bring along your checkbook or other papers that show your account number at a bank, credit union or other financial institution so you can sign up for Direct Deposit, and avoid worries about lost or stolen checks and mail delays.

  Related Information

  • Adult Disability Starter Kit
  • Disability publications
  • Disability Planner
  • Get a form