How to Fill Out and Submit the 1199 Disability Claim Form

The 1199 disability claim form — officially the “Notice and Proof of Claim for Disability Benefits” — is a four-part document you complete with your doctor and employer to apply for up to 26 weeks of short-term disability benefits from the 1199SEIU National Benefit Fund when a non-work-related illness or injury keeps you from your job.¹ The parts are: Part A, your personal information; Part B, your healthcare provider’s medical statement; Part C, your employer’s wage and employment verification; and a direct deposit authorization.² Getting all four completed accurately the first time is the best way to avoid a stalled claim.

Download the current version directly from the 1199SEIU Benefits website, or ask your union delegate or HR department for a paper copy.² An outdated form can be kicked back. One boundary worth naming before you start: this benefit is for non-occupational conditions. Workplace injuries are a workers’ compensation matter, not a National Benefit Fund disability claim.

What to Have Ready Before You Open the Form

Collect everything you and the other signers will need, so the form doesn’t bounce between you, your doctor, and HR more times than necessary:

Your 1199SEIU member ID (from your benefit card or MyAccount portal) and your Social Security number.
Full legal name as it appears in fund records, date of birth, home mailing address, and phone number.
The name, office address, phone, and fax for the doctor who will complete Part B.
Your employer’s name and address, your job title, and the last date you worked before the disability began.
Your bank’s routing number and your account number, if you want benefits deposited directly rather than mailed as a check.

Part A: Your Statement

Part A is yours to fill out. Enter your full legal name exactly as the fund has it on file, your Social Security number, your member ID, your date of birth, and your current mailing address. The form also asks for the date your disability began and a short description of what happened. Be specific. “Herniated disc, L4-L5, diagnosed 3/15/2026” tells the reviewer something; “back problem” does not.

Write legibly if you’re filling the form out by hand. Transcription errors during data entry are a common reason claims stall.

Sign and date Part A before you hand the form to your doctor. An unsigned member statement is an incomplete application, and the fund will send it back.

Part B: Your Doctor’s Statement

Part B goes to the physician treating the condition that keeps you from working. The provider has to supply:

A formal diagnosis with standard medical coding (ICD codes).
The specific date you became unable to perform your job duties, which can differ from the date you first saw the doctor.
A clinical estimate of when you can return to work.
The treatment plan — medications, therapy, surgery, or a combination.
The provider’s signature and date.

Part B is where most claims run into trouble. A diagnosis of “pain” with no underlying condition, or a blank return-to-work estimate, gives the fund nothing to evaluate. If the doctor’s office hands the form back to you for delivery, look through it before you move on. Catching a blank field now saves weeks compared to catching it after submission.

Some providers charge for completing disability paperwork. Those fees are your responsibility and are not reimbursed, so ask about the charge when you drop off the form.

Part C: Your Employer’s Statement

Part C goes to your employer’s HR or payroll department. This section verifies your employment and earnings so the fund can calculate your benefit amount.¹ The employer confirms:

Your last day of actual work before the disability began.
That the absence is due to a non-occupational medical condition, not a workplace injury or a layoff.
Your gross weekly wages before taxes and deductions.
An authorized representative’s signature certifying the reported wages and dates match payroll records.

Hand this to HR as soon as your doctor has finished Part B. Large hospital systems where one office handles paperwork for hundreds of employees can be slow. Follow up within a few business days if you haven’t heard back. Part C is usually the last piece completed before submission, so any delay here delays everything.

Direct Deposit Authorization

The final section authorizes the fund to deposit payments into your bank account. Enter your bank’s routing number, your account number, and whether the account is checking or savings. Direct deposit reaches you faster than a mailed check, which matters when benefits are covering your bills during recovery.

If you skip this section, the fund mails paper checks to the address you entered in Part A. Confirm that address is current, and that someone can collect your mail if you’re recovering somewhere else.

Submitting the Form

Once all four sections are complete, send the form to the 1199SEIU National Benefit Fund. The fund accepts submissions by mail, by fax, and in some cases through its online member portal.¹ The mailing address and fax number for disability claims appear on the form itself; you can also confirm them by calling the fund at (646) 473-9200.³

Before anything leaves your hands:

Photocopy the entire completed form. If something is lost in transit, you’ll need to reconstruct it.
Check every signature. Yours in Part A, the doctor’s in Part B, the employer’s in Part C. A missing signature is an automatic return.
Look through each section one more time for blank required fields that your doctor or HR may have skipped.

If you fax the form, keep the transmission confirmation. If you mail it, use certified mail or a tracked delivery service. The small extra cost buys you proof the fund received your claim on a specific date.

What Happens After You File

The fund generally processes disability claims within two to four weeks after receiving a complete application.¹ During that window, the fund reviews your medical documentation, verifies your employment and wages, and determines whether the claim meets the plan’s requirements.

You can check status by calling (646) 473-9200 or logging into your MyAccount portal on the 1199SEIU Benefits website.⁴ If the fund needs more documentation — a more detailed note from your doctor, updated test results, clarification from your employer — it will reach out in writing or electronically. Respond quickly. An unanswered request for information can get your claim closed.

Once approved, payments begin based on the disability start date your physician confirmed in Part B. They continue for as long as you remain disabled, up to the 26-week maximum.¹ Your health benefits also continue during a disability leave.⁵

If Your Claim Is Denied

The National Benefit Fund is governed by the Employee Retirement Income Security Act, so federal rules apply when a claim is denied. The fund must send a written denial that explains the specific reasons, identifies the plan provisions it relied on, describes any additional information that could strengthen your case, and outlines your right to appeal.⁶

You have at least 180 days from the date you receive the denial letter to file a formal appeal.⁷ That window moves faster than it sounds when you’re also managing medical appointments and lost income. Start gathering new evidence as soon as the denial arrives.

On a disability appeal, the fund must share any new evidence or rationale it plans to use against you before issuing a final decision, giving you a chance to respond.⁷ If the original Part B was too thin, ask your doctor for a supplemental letter that speaks directly to the reason given for the denial. A denial based on “insufficient medical evidence” is often fixable with a more detailed physician’s narrative.

You have to exhaust this internal appeal before you can file a lawsuit. If the appeal is also denied, the denial letter will inform you of your right to bring a civil action under ERISA Section 502(a).⁷

1
1199SEIU Funds. Disability for National Benefit Fund Members
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1199SEIU Funds. Notice and Proof of Claim for Disability Benefits Form
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1199SEIU Funds. 1199SEIU Funds Home
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1199SEIU Funds. 1199SEIU MyAccount
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1199SEIU Funds. Frequently Asked Questions
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Office of the Law Revision Counsel. 29 USC 1133 – Claims Procedure
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eCFR. 29 CFR 2560.503-1 – Claims Procedure