Disability Certificate

(To be completed by employee)

Employee's name:

Home phone:

Home address:

I authorise the physician to release necessary information to the below company regarding my condition while under his/her care.

Employee's signature _____________ Date:

****** To be completed by attending physician ******

Date disability began

Expected return to work date

Nature of disability:

Special complications Work restrictions:

Work restrictions:

Date(s) seen:

If hospitalized, name of hospital:

Dates: From ____________ To: ____________

Date of surgery, if any

Procedure:

If pregnancy, expected date of delivery:

Physician's name:

Address:

Phone number:

Return to:

________________________ Date:

Signature