Disability Claim Filed and Request for Information - Form E-15
To notify the employer that the worker is claiming temporary disability benefits.
To secure from the employer wage and separation information needed to determine the claimant's eligibility. (See Form)
We use this information to determine if the claimant is potentially eligible for benefits.
Use by Employer
If required wage and separation information is not provided on a claim for temporary disability benefits, the Division sends the employer Form E-15, which must be completed on both sides, signed and returned to the Division within 10 days of the date of mailing.