Proof of Workers' Compensation And/Or Similar Benefits

If you receive or received any temporary or permanent workers' compensation-type benefits, we need to see award letters, pay stubs, settlement agreements or other proof you might have.

We will need documents that show:

• The date of your injury or illness;
• The amount and effective date of your current payment and all increases or decreases within the last 17 months or, if later, since payments began;
• if receiving workers' compensation, the type of payment (i.e., temporary partial, temporary total, permanent partial, permanent total, a lump sum or an annuity;
• The frequency of your payments (e.g. weekly, bi-weekly, monthly, bi-monthly, etc.) or the period covered by a lump sum;
• If benefits have already ended, the last day you were entitled to a payment and your last payment amount (if different than your regular payment amount);
• Your employer's name and address; and
• If other than your employer, the name and address of the insurance carrier making the payments.

For your convenience, we can accept uncertified photocopies of your workers' compensation and/or similar benefit information. We will return all documents and photocopies unless you specifically tell us otherwise. If you have the documents we need, you should submit them as soon as possible. If you don't have all the documents, you should submit any documents you do have. We will help you get the other documents. Do not delay sending your application while gathering evidence. If you do, you may lose benefits.