Next Step
A Unique Workforce Partnership Forging Change		 International Brotherhood of Electrical Workers  Verizon CWA
A Cooperative Educational Program
VERIZON • IBEW • CWA

New York Student Disability Reporting Form
(For NY Managment Reporting Only)

(* = required field)

* Associate's First Name:
* Associate's Last Name:
* Associate's EMPLID:
* Date of Disability:
MetLife Approval Date:
Anticipated Return to Work Date:
* Supervisor's Name:
* Supervisor's Phone:
(xxx-xxx-xxxx)
* Supervisor's Email:
* Verify Email:
Once you have submitted the disability form, you will be given a confirmation form to review the information being submitted. Upon reviewing this form, please hit Email Next Step Office, to complete the submission to the Next Step Office