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Weekly Indemnity Claim |
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Use
You've become disabled (through injury or sickness) and are no longer able to work.
Use the Weekly Indemnity
Benefits Claim form to make your claim for Weekly Indemnity
benefits.
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Information Needed to Complete the Form
Your personal Member information is needed to complete the form.
The policy number, 9000 must be
included on the form. In addition, information
such as:
- details of the sickness and/or accident,
- your employer's statement and signature,
- the physician's contact information, and
- the attending physician's statement and signature
is also required.
Please follow the instructions on the form. |
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Notes
- Your claim must be filed within 30
days of becoming disabled.
- Both your employer and your doctor must complete their sections
of the form before the claim will be considered.
- The Member must sign on both
pages of the form.
Questions on completing the form should be directed to the Plan
Administrator.
Completed forms should be sent to the Plan
Administrator. |
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Plan Administrator
Millworkers Health & Welfare Plan (Unifor)
Administrator
c/o D.A. Townley
4250 Canada Way
Burnaby, BC, V5G 4W6
Phone: 604-299-7482 or 1-800-663-1356
Fax: 604-299-8136
Email: Health
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PDF
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