Long Term Disability

"*" indicates required fields

MM slash DD slash YYYY
MM slash DD slash YYYY
Pensions Scheme Member?*
Private Health Cover?*

Contact Details

Shift Work?*

Manager’s contact details

Management report to be sent to

Please indicate the information you require from the occupational health professional:*
I confirm that this referral has been fully discussed with the individual and that they understand the reason for the referral to an occupational health professional.
MM slash DD slash YYYY
Accepted file types: xls, xlsx, doc, docx, pdf, Max. file size: 50 MB.
Please submit a copy of the employee’s job description with this referral


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