Forms For Employee/Claimant To Download


Click on a form to download.



ERISA STD/LTD Disability Forms

Physician's Certificate for Disability Benefits - PDF
If your Physician prefers to submit a paper form rather than phone Sedgwick with your initial medical certification, please download this form, complete Part 1 and give it to your Physician to complete and return to Sedgwick.

Request for Extension of Self-Insured Disability Benefits - PDF
If you have not recovered or you are not able to return to work on your scheduled return to work date, and your Physician is unable or unwilling to phone Sedgwick with your extension for disability benefits, download this extension form, complete Part 1 and give it to your physician to complete and return to Sedgwick in order to continue your disability benefit payments.

Authorization for Release of Information (ROI) - PDF
Every new STD/LTD leave request filed with Sedgwick requires this completed form. Please download this form, complete and sign both sections and return it to Sedgwick immediately. If you complete this form prior to receiving the form in the mail, please ignore the one you receive in the mail. Sedgwick only needs one copy of this signed form for our files.

Right of Reimbursement (ROR) - PDF
Every new STD/LTD leave request filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

State Statutory Paid Family Leave Forms

Physician's Certificate For Paid Family Leave - PDF
If your Physician prefers to submit a paper form rather than phone Sedgwick with your initial medical certification, please download this form and immediately give it to the Physician to complete and return to Sedgwick.

California Paid Family Leave Bonding Evidence of Relationship (CA_EOR) - PDF
For specific information on what constitutes evidence of relationship in California with your child for bonding purposes, please download this informational document.

New Jersey Paid Family Leave Bonding Evidence of Relationship (NJ_EOR) - PDF
For specific information on what constitutes evidence of relationship in New Jersey with your child for bonding purposes, please download this informational document.

Authorization for Release of Information Paid Family Leave Bonding (ROI) - PDF
Every new claim filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Right of Reimbursement for Paid Family Leave (ROR) - PDF
Every new claim filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Care Recipient's Authorization for Release of Information Paid Family Leave (ROI) - PDF
Every new claim filed with Sedgwick requires this completed form. Please download this form, have the care recipient complete and sign it, and immediately return the form to Sedgwick. If the care recipient completes this form, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Authorization for Release of Information for Paid Family Leave (ROI) - PDF
Every new claim filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Right of Reimbursement for Paid Family Leave Bonding (ROR) - PDF
Every new claim filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Request for Extension of Paid Family Leave Benefits - PDF
If you're family member has not recovered and you are not able to return to work on your scheduled return to work date; and your family member's Physician is unable or unwilling to phone Sedgwick with your extension for benefits, download this extension form. Complete Part 1 and give it to your family member's physician to complete and return to Sedgwick in order to continue your paid family leave benefit payments.

Family Medical Leave Certification Forms

CFRA (California Family Rights Act) Certification for Employee's Own Serious Health Condition - PDF
This form is applicable for California employees that have filed for Unpaid Leave (FML or CFRA). Please download this form and have your Physician complete it and return it to Sedgwick immediately.

FML (Family Medical Leave) Certification for Employee's Own Serious Health Condition - PDF
This form is applicable for employees that have filed for Unpaid leave (FML). Please download this form and have your Physician complete it and return it to Sedgwick immediately.

FML (Family Medical Leave) Certification for Family Member's Serious Health Condition - PDF
This form is applicable for employees that have filed for Unpaid leave (FML) to care for a family member who has a serious health condition. Please download this form and have your family member's physician complete it and return to Sedgwick.

FML (Family Medical Leave) Certification for Service Member's Serious Health Condition - PDF
This form is applicable for employees that have filed for Unpaid leave (FML) to care for a covered service member who has a serious health condition. Please download this form and have your family member's physician complete it and return to Sedgwick.

FML (Family Medical Leave) Certification for Qualifying Exigency - PDF
This form is applicable for employees that have filed for Unpaid leave (FML) for qualified exigency leaves. Please download this form and have it completed and returned to Sedgwick.

FML (Family Medical Leave) Certification for Child Over 18 Years of Age - PDF
This form is applicable for employees that have filed for Unpaid leave (FML) for care for a child who is over the age of 18. Please download this form and have it completed and returned to Sedgwick.

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