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The Standard SI 9426: NJ State Disability Claim APS

The Standard uses this five-page packet for New Jersey state disability benefit claims under an employer's private plan that it insures. Page 3 is the Attending Physician's Statement, which documents the patient's inability to work. The Standard says it takes about one week to decide a claim once the complete application arrives, and benefits usually stop when the patient returns to work.

Who completes it

The employer completes the Employer's Statement, and the employee completes the Employee's Statement and authorization and writes their name and employer at the top of page 3. The treating physician completes the rest; each physician treating the disabling condition completes a separate statement.

Submitting and payment

How to submit it
The physician statement says to mail it to The Standard at the printed address, and the packet also lists email and fax for the full claim.
Who pays
The form states the patient is responsible for completing the Attending Physician's Statement at their own expense.

Good to know

  • Item 5 asks for functional limits in a workday with two breaks and a meal break: lift and carry ranges, hours of sitting, standing and walking, and how often the patient can bend or stoop.
  • Pregnancy claims need the expected and actual delivery dates, vaginal or C-section delivery, and any significant complications.
  • The physician states whether the patient is competent to manage insurance benefits and, if not, whether the patient can appoint someone to help manage them.
  • Item 3 asks whether the condition is work related and whether a Workers' Compensation claim form was completed; the packet notes other benefits can affect the New Jersey disability payment.

Get the official form

Download the current version from the source each time; forms change without notice.

New Jersey State Disability Claim – Attending Physician's Statement

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who pays for The Standard's New Jersey attending physician statement?

Page 3 of SI 9426 says the patient is responsible for completing the form at their own expense. The cost of completion therefore falls on the patient, not on The Standard. The statement documents the patient's inability to work for the New Jersey state disability claim.

How long does The Standard take to decide a New Jersey disability claim?

The packet says a claim decision takes about one week after The Standard receives the completed application. If no decision is reached in that time, the claimant is notified with the details. A complete Attending Physician's Statement from each treating physician is part of that application.

What prognosis options does SI 9426 offer?

Item 7 asks whether the condition has improved, not changed or retrogressed since symptoms began, and when the patient can return to work: a specific date, unable to determine with follow-up in a set number of weeks, or never.