Welcome,

Edgewell

Streamline your experience with Acclaim! Our forms are designed with simplicity in mind, ensuring a smooth and hassle-free process. Take the first step towards efficient claims management by filling out the form below—empowering you to access the support you need effortlessly.

Fields marked with an * are required.

Hidden Fields

Internal note: These fields will be hidden on page-load. Please ensure the correct Company ID and Company Name are inputted.

Company ID

Company Name*

Form Name*

Type of Claim^*

Short Term Disability

Type of Employee^*

Not Applicable

Employee First Name^*

Employee Last Name^*

Employee Preferred Email^*

Employee Primary Phone^*

Employee Secondary Phone

Date of Birth^*

Preferred Language^*

Employee Address^*

Apartment, Suite, Etc.

City^*

Province/State^*

Country^*

Postal/Zip Code^*

Position^*

Last Day Worked^*

First Day of Absence^*

Comments

Medical Notes

Max file size 10MB.

Step

Submit

We Have Received Your Request To Start A Claim

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