First name Last name Specialty Phone number Fax number Dates of treatment From To Reason for treatment Have you been hospitalized? If Yes, give dates from to Yes No Inpatient Outpatient Name of hospital Address of hospital City State ZIP code Cross highest education level completed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Degrees, certificates, license/skills or training obtained Please describe what prevents you from performing the duties of your job. Have you applied for or are you receiving income from any other sources? Yes No If yes, provide the following information. Applied Receiving $ Amount Frequency From date To date for (mm/dd/yyyy) (mm/dd/yyyy) Salary continuance/Sick leave Short term disability Worker’s compensation State disability Social Security Dependent Social Security No fault (Income replacement) Retirement/Pension Permanent total disability Other (Please identify) Page 3 of 9 EES-LTD-5323 (08/20) Fs/f