Downloads

Claim Form

Work Accommodation – Introductory Memo with Claim Forms

Medical Leave of Absence – Introductory Memo with Claim Forms

Medical Leave of Absence – Leader Responsibility Checklist

Medical Leave of Absence – Return to Work – Leader Responsibility Checklist

Medical Leave of Absence – Leader Guide

Medical Leave of Absence – Associate Guide

Log Out

Welcome,

Napoleon

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^*

Medical Monitoring

Work Accommodation

Other

Type of Employee^*

Hourly

Salary

Employee First Name^*

Employee Last Name^*

Employee Preferred Email^*

Employee Primary Phone^*

Employee Secondary Phone

Date of Birth^*

Gender^*

Employee ID Number

Preferred Language^*

Employee Address^*

City^*

Province/State^*

Country^*

Postal/Zip Code^*

Site/Location

Department

Position^*

Date of Hire

Last Day Worked^*

First Day of Absence^*

Regular Hours Worked Per Week

Whomever is listed below will be provided with updates regarding the status of this claim.

Manager Contact

Manager Name

Manager Email

Manager Phone Number

Supervisor Contact

Supervisor Name

Supervisor Email

Supervisor Phone Number

HR Contact

HR Full Name

HR Email

HR Phone Number

Comments

Medical Notes

Max file size 10MB.

Step

Submit

We Have Received Your Request To Start A Claim

Thank you for reaching out to us! Your form has been successfully submitted. Rest assured, our team is already at work reviewing the details you provided. We appreciate your trust in Acclaim, and we'll be in touch soon to discuss and address your needs.

Go Home Log Out

Oops! Something went wrong while submitting the form.

Double check to make sure all fields are inputted correctly. If you're still having issues, please contact us for support.

Get Help