First name Middle name Last name Date of birth (mm/dd/yyyy) Social Security number First name Middle name Last name Date of birth (mm/dd/yyyy) Social Security number SECTION 2: Claim information Is your disability due to Injury/Accident? Illness? If due to injury/accident, give date, time and details. (When, where, how) Is this condition work related? Yes No Date of first treatment for this condition (mm/dd/yyyy) Date last worked (Must answer) (mm/dd/yyyy) Date disability began (mm/dd/yyyy) Primary attending physician First name Last name Address City State ZIP code Phone number Name of physicians/providers who have treated you within the past 2 years. First name Last name Specialty Phone number Fax number Dates of treatment From To Reason for treatment First name Last name Specialty Phone number Fax number Dates of treatment From To Reason for treatment Page 2 of 9 EES-LTD-5323 (08/20) Fs/f