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?
Why did your employee stop working?
Were there any changes to your employee's job responsibilities prior to the last day of work?
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 employee returned to work, he/she returned:

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?
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 this is an LTD claim, does the employee pay any of the LTD insurance premium?
(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?
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 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

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 subject to fines, confinement in prison and/or denial of insurance benefits. This warning applies to the following states: Alabama, Alaska, Arkansas, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana, Iowa, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia, West Virginia, Wisconsin, Wyoming.
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.
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: 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.
DISTRICT OF COLUMBIA WARNING: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.
FLORIDA WARNING: 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.
GEORGIA WARNING: WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
KANSAS 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 fraud, as determined by a court of law, and subject to fines, confinement in prison and/or denial of insurance benefits.
KENTUCKY WARNING: 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.
LOUISIANA 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 subject to fines, and confinement in prison.
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: WARNING: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NEW HAMPSHIRE WARNING: 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 YORK 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
OREGON WARNING: WARNING: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer by submitting an application, or by filing a claim containing a false statement as to any material fact, may be violating state law.
PENNSYLVANIA WARNING: 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 WARNING: WARNING: It is a crime to knowingly supply 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.
WASHINGTON WARNING: 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.
Signature: You will be prompted for your signature at a later date.
Date: The date will be filled upon receiving your signature.