Short Term Disability Request Form

Short Term Disability Request Form
Full Legal Name*

First NameLast Name
CPR Email Address*
example@example.com
What was your hire date?*

MonthDayYear
Date
Did you elect STD during your benefits enrollment?*

YesNo
Why are you requesting Short Term Disability? *
This information is confidential and will only be seen by the HR department.

What is your expected STD start date?*

MonthDayYear
Date
Are you currently on FMLA?*

YesNo
Have you filed your STD claim with the carrier?*

YesNo
Please log on to Mutual of Omaha to file your claim if you have yet to complete it:

Mutual of Omaha STD Claim Form
What is your expected return to work date?*

Due to you waiving Short Term Disability, this benefit does not apply. If you have any questions email hr@cprecovery.com. Thank you!
Your STD submission is confidential. The health information included will not be viewed by anyone other than HR; however, your supervisor will be notified of the leave request.
Supervisor's Full Legal Name*

First NameLast Name
Supervisor's CPR Email*
example@example.com
Should be Empty: