B. Give this form to the physician treating you. (If more than one physician is treating you, obtain additional forms from your employer.

Transcription

1 hone umber: (866) Fax: (877) UY FZ71778 roup Long-erm Disability laim Form eturn to Dearborn ational at: ttention laims Department.. Box Dallas, exas : ll portions of this form package must be completed to avoid undue delay in processing claimant's request for benefits. L F LD BF mployee's nstructions. omplete employee claim statement in full, and be sure to sign the uthorization. his will allow Dearborn ational or its representative to secure additional information if necessary to make a decision on your claim. B. ive this form to the physician treating you. (f more than one physician is treating you, obtain additional forms from your employer.) When your physician returns the completed form to you:. ttach: copy of your birth certificate (only if disability is indefinite and you are over age 50) copy of ocial ecurity and other income entitlement awards; and B. eturn with all attachments, to Dearborn ational at address above. D Y' () hysician's nstructions s soon as the claimant gives you this form:. omplete the on page 3 of the form in its entirety, being careful to answer each question. f the answer is none, or if the question is not applicable, please so indicate. B. s soon as you have fully completed the form, sign, date, and return to the claimant. ur timely review of this claim for disability benefits depends on you. hank you for your prompt response. Y W KWLY D W DFUD Y U Y FL L F U F L Y LLY FL F L F U F LD, F Y F L FUDUL U, W D UBJ U L D VL L. (ot enforceable in regon or Virginia.) roducts and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers rove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, uam and uerto ico. age 1 of _12 X6136_uts

2 L L Y L Y mployee s laim tatement o be ompleted by mployee 1. Full ame (Last, First, iddle nit.) 2. aiden ame 3. lias ame 4. Benefits D o. 5. hone umber ( ) 6. ddress ity tate Zip ode 7. Date of Birth 8. eight 9. Weight 10. ex 11. arital tatus 12. pouse's date of birth 13. s spouse employed? q q ingle q arried o. Day Year q F q Widowed q Divorced qyes o. Day Year ft. in. lbs. First ame qo 14. umber of children 15. List names and dates of birth of unmarried children who have not finished high school. (Under age 19) 16. mployer's ame 17. roup olicy o. 18. ccupation (List the duties of your occupation at the time of disability) 19. Date of accident or date 20. have been unable to work 21. returned to work on 22. returned to work on a full first noticed symptoms because of the disability a part time basis on: time basis on: of illness: since: o. Day Year o. Day Year o. Day Year o. Day Year 23. s your accident or illness 24. ave you or do you intend to file a Workers omp. laim? q Yes q o related to your occupation? f yes, explain q Yes q o 25. Describe how and where accident occurred or describe the onset and nature of your illness. 26. Date you were 27. reated by: first treated for your illness or injury. o. Day Year 28. ave you ever 29. reated by: had the same or similar condition ospital: in the past? ame treet ddress ity tate Zip ode q Yes q o f yes complete o. 29. UY FZ71778 ospital: ame treet ddress ity tate Zip ode Doctor: ame treet ddress ity tate Zip ode Doctor: ame treet ddress ity tate Zip ode 30. Describe other income you are receiving: Date Date Yes o ype mount Began erm. q q h ocial ecurity (disability or retirement) $ q q tate disability $ q q etirement (normal, early or disability) $ q q Workers' ompensation $ q q roup disability benefits $ q q ther (describe) $ 31. ave you applied, or do you plan to apply for benefits described above? q Yes q o ype Date application filed ype Date application filed 32. f your request for benefits is approved, do you want us to withhold amounts from each benefit for Federal ncome ax purposes? q Yes q o f yes, please complete and attach Form W4. UZ: authorize any medical professional or provider, hospital, medical facility, clinic, pharmacy, overnment gency or insurance company to disclose to Dearborn ational Life nsurance ompany's (Dearborn ational) claim department, reinsurers or authorized representatives information about my medical history or treatment and/or to furnish copies of my hospital and/or medical records including information concerning advice, care or treatment for any condition, including but not limited to drug or alcohol use or abuse, mental illness, V (D Virus) or other sexually transmitted diseases. also authorize my employer to disclose all information needed to process my claim. his authorization expires on the date receive notice of Dearborn ational's final claim decision. may revoke this authorization at any time, but such a revocation will have no effect on any actions taken by Dearborn ational prior to receipt of the revocation. nformation provided pursuant to this authorization may be redisclosed by the recipient and no longer subject to the protections of the rivacy ule. photocopy of this authorization is as valid as the original. understand that should retain a copy of this authorization for my records and that my personal representative or have a right to obtain a copy of my authorization from Dearborn ational. f my answers on this claim form are incorrect or untrue, or if refuse to sign this authorization, Dearborn ational has the right to deny my claim. ignature of mployee Date roducts and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers rove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, uam and uerto ico. age 2 of _12 X6136_uts

3 ame of patient Y D Date of Birth ttending hysicians tatement (a) When did symptoms first appear or (b) Date patient ceased work (c) as patient ever had same or similar condition? accident happen? because of disability? q Yes f "Yes" state when and describe q o (d) s condition due to injury or sickness (e) ames and addresses of other treating physicians arising out of patient's employment? q Yes q o q Unknown (a) Diagnosis (ncluding complications) lease submit all office notes in regard to this condition* * lease submit bill for records with this claim. UY FZ71778 (b) ubjective symptoms (c) bjective findings (ncluding current x-rays, K's, laboratory data and any clinical findings?) (a) Date of first visit (b) Date of last visit (c) Frequency q Weekly q onthly q ther (pecify) (d) ature of treatment (ncluding surgery and medications prescribed, if any) D B K (a) as patient q ecovered? q mproved? (b) s patient q mbulatory? q ouse confined? q Unchanged? q etrogressed? q Bed confined? q ospital confined? (c) as patient been hospital confined? q Yes q o onfined from through f, yes, give ame and ddress of ospital: (a) Functional capacity (*merican eart ss n.) (b) Blood ressure (last visit) q lass 1 (o limitation) q lass 2 (light limitation) q lass 3 (arked limitation) q lass 4 (omplete limitation) (a) hysical mpairments (*s defined in Federal Dictionary of ccupational itles). q lass 1 - o limitation of functional capacity; capable of heavy work* o restrictions. (0-10%) q lass 2 - edium manual activity* (15-30%) q lass 3 - light limitation of functional capacity; capable of light work* (35-55%) q lass 4 - oderate limitation of functional capacity; capable of clerical/administrative (sedentary*) activity. (60-70%) q lass 5 - evere limitation of functional capacity; incapable of minimum (sedentary*) activity. (75-100%) emarks: (b) ental mpairments (f applicable) (a) lease define "stress" as it applies to this claimant. (b) What stress and problems in interpersonal relations has claimant had on job? q lass 1 - atient is able to function under stress and engage in interpersonal relations (no limitations) q lass 2 - atient is able to function in most stress situations and engage in most interpersonal relations (slight limitations) q lass 3 - atient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations) q lass 4 - atient is unable to engage in stress situations or engage in interpersonal relations (marked limitations) q lass 5 - atient has significant loss of psychological, physiological, personal and social adjustment (severe limitations) emarks: (a) s patient now totally disabled? ' JB qyes q o (b) Date patient became disabled due to Y WK q Yes q o present illness (c) When do you expect a fundamental or marked change in the future? q 1 o. q 1-3 o. q 3-6 os. q ever. pplies o: q atient's job q ther Work (a) s patient a suitable candidate ' JB Y WK (b) an present job be modified to allow for for occupational rehabilitation? q Yes q o q Yes q o handling with impairment? q Yes q o (c) When could trial employment commence? Date q Full-time Date q Full-time 's job q art-time Y WK q art-time (Limitations, herapy, etc.) ame (ttending hysician) rint Degree elephone ( ) Fax #: ( ) treet ddress ity or own tate Zip ode ignature Date roducts and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers rove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, uam and uerto ico. age 3 of _12 X6136_uts

4 Fraud otices dministrative ffices: Downers rove, llinois Dallas, exas he laws of some states require us to furnish you with the following notice: For pplications and laims: olorado: t 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. enalties may include imprisonment, fines, denial of insurance, and civil damages. ny 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 olorado division of insurance within the department of regulatory agencies. District of olumbia: W: t is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. enalties include imprisonment and/or fines. n addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida: ny 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. awaii: For your protection, awaii law requires you be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Kentucky: ny 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 conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Louisiana: ny 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 aine & Washington: t is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. enalties include imprisonment, fines and denial of insurance benefits. aryland: ny person who knowingly or willingly 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 ew exico: ny 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. hio: ny person who, with intent to defraud or knowingly 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. klahoma: ny person who knowingly, with intent to injure, defraud or deceive any insurer, makes a claim for the proceeds of an insurance policy containing false, incomplete or misleading information is guilty of a felony. ennsylvania: ny 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. uerto ico: ny person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand dollars($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. hould aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. hode sland: ny 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 ennessee: t is a crime to knowingly provide false incomplete or misleading information to an insurance company for the purpose of defrauding the company. enalties include imprisonment, fines and denial of insurance benefits Virginia: t is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. enalties include imprisonment, fines and denial of insurance benefits. roducts and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers rove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, uam and uerto ico. age 1 of _12 Z6291

5 he laws of some states require us to furnish you with the following notice: Fraud otices dministrative ffices: Downers rove, llinois Dallas, exas F L LY: laska: 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. rizona: For your protection, rizona law requires the following statement to appear on this form. ny person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. rkansas: ny 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 alifornia: For your protection alifornia law requires the following to appear on this form. ny person who knowingly presents false or fraudulent claim for the payment of a loss is and confinement in state prison. Delaware: ny 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. daho: ny person who knowingly, and with intent to defraud or deceive any insurance company, files a statement or claim containing false, incomplete, or misleading information is guilty of a felony. ndiana: 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. innesota: person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. ew ampshire: ny 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 638:20. ew Jersey: ny person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. exas: ny 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. F L LY: assachusetts: ny 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 ew Jersey: ny person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. roducts and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers rove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, uam and uerto ico. age 2 of _12 Z6291