EMPLOYER’S STATEMENT OF
CLAIM FOR BENEFITS


As your disability insurance provider, we are committed to assisting your employee in a return to productive employment. Please complete the following information thoroughly, as this will allow us to accurately evaluate this claim and assist your employee with a successful return to work. An incomplete claim form will not be accepted.

Employee's name:
Social security number:
Street
City
State
Zip Code
Telephone number:
Date of Birth:

EMPLOYEE INFORMATION

Employee's date of hire:
Date employee became insured for benefits:
What was the employee's permanent job on his or her last day of work?
How long had the employee been in this job?
Last date employee actually worked
On the last day worked did the employee work a full day?
If no, how many hours were worked?
Why did your employee stop working?
Were there any changes to your employee's job responsibilities prior to the last day of work?
If yes, what were the changes and when were they made?
What is your employee’s regularly scheduled work week?
Hours per week.
Hours per day.
Hourly wage if applicable:
What was your employee's Basic ANNUAL Salary as of his/her last day of work?
Has your employee returned to work?
If yes, Part-time date:
Full-time date:
If employee returned to work, he/she returned:
If the employee returned with restrictions, please indicate the specific restrictions:

SALARY / OTHER INCOME / TAX INFORMATION

Type of benefit this claim is being filed for? (Please check all applicable claims):
If claim is for Life Insurance Waiver of Premium benefits, please indicate:
Effective date of coverage:
Basic Coverage Amount($):
Supplemental Coverage Amount($):
Total Number of dependents: Spouse Children

How many contract days does this employee work?
Total number of sick days employee has:
If your employee worked based on contracted days, please provide a calendar documenting each contract day.
Has your employee received or will he/she receive any pay from the following:
If you checked any of the above please complete the following: The employee received pay from to


in the amount of per


Is the employee's disabling condition work-related?
Has a claim been filed with Workers' Compensation?
If yes, what is the current status of the Workers' Compensation claim?
Please send any Worker’s Compensation claim information that you may have including benefit payment information if applicable.
If this is an STD claim, does the employee pay any of the STD insurance premium?
If yes, the contribution is:
If “Post-tax”: Post Tax % paid by employer
Post Tax % paid by employee
Post Tax Dollar amount paid by employer
Post Tax Dollar amount paid by employee
If this is an LTD claim, does the employee pay any of the LTD insurance premium?
If yes, the contribution is:
If “Post-tax”: Post-tax % paid by employer
Post-tax % paid by employee
Post-tax dollar amount paid by employer
Post-tax dollar amount paid by employee
(Note: If employee paid disability premium is pre-tax, we will deduct FICA tax as if the employer was paying 100% of the disability premium.)
To the best of your knowledge, is your employee receiving, or entitled to receive benefits from any of the following as a result of this disability:
FOR ANY YES ANSWER PLEASE PROVIDE THE FOLLOWING INFORMATION:
Name and address of carrier or administrator

Telephone Number:

RETURN TO WORK CONSIDERATIONS
(Complete if employee has not yet returned to work)

Does your company/organization have a return-to-work policy for disabled employees?
Do you, or does someone from your company/organization, maintain contact with your employee?
Frequency?
Can you provide transition job duties for your employee to allow a gradual return to work?
Has this information been communicated to your employee's physician?
Have you discussed a return to work with your employee?
What is the anticipated return to work date?
What is the name, telephone number and title of the supervisor we should contact if we identify a rehabilitation or return-to-work option?
Name
Title
Telephone Number
Would you like a Vocation Rehabilitation Case Manager to assist your employee in the return to work process?
Do you have any other comments which might help us better manage this claim?
PLEASE ATTACH A JOB DESCRIPTION OUTLINING THE JOB DUTIES AND PHYSICAL DEMANDS OF THIS EMPLOYEE’S OCCUPATION
Attach File
Attach File

Attach Files

Attach File
Attach File
Attach File
Attach File

CONTACT INFORMATION

Employer's Group Name
Group/Policy number
Street
City
State
Zip Code
Name of individual completing this form
Title of individual completing this form
Telephone number:
Fax number:
Email address:
I have received and read the fraud warning statements provided with this form
Signature: You will be prompted for a signature at a later date.
Date: The date will be filled upon receiving your signature.

FRAUD WARNINGS

The following Fraud Warning applies to these states: Connecticut, District of Columbia, Georgia, Hawaii, Illinois, Iowa, Kansas, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oregon, South Carolina, South Dakota, Utah, Vermont, Wisconsin and Wyoming.

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
STATE SPECIFIC FRAUD WARNINGS
ALABAMA WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
ALASKA WARNING: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
ARIZONA WARNING: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
ARKANSAS, LOUISIANA & WEST VIRGINIA WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
CALIFORNIA WARNING: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
COLORADO WARNING: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damage. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the Department of Regulatory Agencies.
DELAWARE & IDAHO WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
FLORIDA WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
INDIANA WARNING: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
KENTUCKY WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
MAINE WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MARYLAND WARNING: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
MASSACHUSETTS WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines, confinement in prison and/or denial of insurance benefits.
MINNESOTA WARNING: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
NEW HAMPSHIRE WARNING: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
NEW JERSEY WARNING: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
NEW MEXICO WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
OHIO WARNING: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PENNSYLVANIA WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
TENNESSEE, VIRGINIA, & WASHINGTON WARNING: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
TEXAS WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in the state prison.
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