WELCOME TO DEARBORN NATIONAL UNDERWRITTEN BY DEARBORN NATIONAL LIFE INSURANCE COMPANY

Transcription

1 Partnership. olutions. trength. WL DB L UDW BY DB L LF U PY Guide to laims Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany, (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Product features and availability vary by state and company, and are solely the responsibility of each affiliate.

2 GUD L Group dministration BL F : GUD L UBG L D GG F FLG L Death laim hort-erm Disability laim Long-erm Disability laim X PG GUDL axability of Disability Benefits Year-nd ax eporting 2 of 14 (11/15)

3 GUD L Group dministration his guide is designed to assist you in the administration of your group insurance plan. By providing accurate information and updating changes to the records that you provide to Dearborn ational, we will establish a successful partnership in the administration of your plan. key identifier for all documents you send to Dearborn ational is the group and account number. Please include these numbers on all communications. We recommend that all persons involved in the administration of your group insurance plan familiarize themselves with all administrative procedures and forms. o understand the rights and obligations of all parties, refer to your group master policy. UBG L D GG F UBG L laims can be submitted by: 1. ail the claim form to Dearborn ational at the address listed on the form. 2. Fax the claim form to the number on the form. 3. nline at for Life, D&D, ritical llness or Waiver of Premium laims. Please be prepared to attach the required documents when submitting claims online. ote: You must be a registered user of Benefit anager. GG F n our Web site, you can obtain forms by clicking the Forms tab on our Home page and select Group Benefits. Follow the on-screen instructions. Please complete the appropriate claim form for the type of claim being submitted. here are specific claim forms to be used when submitting Death/ccidental Death, Dismemberment, ccelerated Death Benefit, D and LD claims. ost claim forms contain sections to be completed by the employer, the employee and the attending or treating physician. ote: ll sections must be completed in their entirety, and appropriate signatures from the employer, employee and attending physician must be provided in order for the claim to be considered a complete claim submission. ompleted forms and any additional documentation should be mailed or faxed to the address or fax number shown on the claim form. Questions regarding procedures or proper use of forms and claim status should be directed to the Dearborn ational laim ustomer ervice department at When competing any of the claim forms, please follow the instructions carefully. UBG DH L he following documents must accompany the claim submission: 1. certified death certificate with a seal for total coverages of more than 25,000. f coverage is 25,000 or less and the death occurred in the United tates, a copy of the certified death certificate will be accepted, and 2. he insured s original beneficiary designation form, as well as any changes made subsequently. 3. For voluntary coverage, proof of enrollment and payroll deduction are required as applicable. ee sample on page 4. (ote: nly sections of the actual form are displayed here.) 3 of 14 (11/15)

4 GUD L Group dministration DH L F Phone umber: (800) Fax: (312) Death laim Form eturn to Dearborn ational at: ttention: laims Department st treet Downers Grove, L U he employer/administrator must complete the claim form as indicated and send attachments mentioned below. We will advise you if further documentation is necessary to complete the claim process. Please submit the following documentation: 1. Death laim Form: Part 1 ompleted by the mployer/dministrator Part 2 - ompleted by the Beneficiary(ies) 2. riginal, photocopy or screen print of enrollment form, including any beneficiary changes. 3. certified copy of the official death certificate. 4. f the benefits are based on salary, payroll records verifying the insured s annual earnings at the time of death. 5. f any portion of coverage is paid for by the insured, proof of payroll deduction. 6. For accidental death benefits, provide the following: a. fficial completed police report b. Proof of seatbelt/airbag use if applicable c. ewspaper clipping(s) of accident, if applicable d. oroner s report, findings and/or toxicology report 7. f the Beneficiary is: a. minor, an estate or incompetent to handle financial matters: provide an original court order appointing a legal representative or guardian to handle the financial affairs of the minor, the estate, or the incompetent. b. Deceased: provide proof of death, a copy of the final certified death certificate, and documentation of the secondary beneficiary. c. trust: provide documentation verifying existence of the trust, documentation that the trust has been named the beneficiary, and the tax identification number of the trust. 8. ach beneficiary must complete and sign the Beneficiary/laimant tatement. Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 1 of Z of 14 (11/15)

5 GUD L Group dministration DH L F Phone umber: (800) Fax: (312) Part 1 - o be completed by mployer/dministrator tatement of mployer mployer/plan nformation Group ame Group umber ubsidiary ame ccount#/division Death laim Form eturn to Dearborn ational at: ttention: laims Department st treet Downers Grove, L ddress: ame and itle of uthorized epresentative Phone umber -ail ddress treet ity tate Zip Fax umber Preferred communication: -mail Phone Fax Deceased Person nformation (include ertified opy of Death ertificate) ame Last First iddle elation to mployee/ember of Death nsured Person nformation ame of laimant Last First iddle ocial ecurity o. lass of Birth Hire ccupation nsurance ffective nnual alary of Last alary ncrease Work chedule hrs/wk (f salary based benefit or if any portion of premium is contributory please submit proof of payroll deduction) Last Day Worked eason for cessation of work of Last Premium ontribution: Group ember (resignation, disability, retirement, illness, layoff, leave of absence, vacation, other - please list) f etired, of etirement f erminated of ermination f Disabled, of Disability Waiver of Premium: o ontinuation of Life nsurance: o xtended Life: o Beneficiary(ies) (include address and phone #) nline Beneficiary racking: o racking ystem mount of nsurance: Basic Life dditional Benefits eat Belt upplemental Life ir Bag D&D ritical llness Voluntary Life ducation Dependent Life ther f Deceased is a Dependent hild, Please omplete the Following: Dependent hild's of Birth Full-ime tudent: o chool s He/he ncapacitated and eliant on the mployee for Financial upport: o certify that have read this document and the information is accurate and complete. understand that any person who knowingly files a statement of claim containing any false or misleading information may be subject to criminal and civil penalties. ignature of uthorized mployer/plan epresentative Print ame Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 2 of Z of 14 (11/15)

6 GUD L Group dministration DH L F Phone umber: (800) Fax: (312) Death laim Form eturn to Dearborn ational at: ttention: laims Department st treet Downers Grove, L Part 2 - o be completed by Beneficiary *f there is more than one beneficiary, each must completed a separate form.ee nstructions page f beneficiary is a minor ame: aiden ame of Birth ddress: Phone Last First iddle lias ame ocial ecurity o. treet ity tate Zip -ail elationship to Deceased omments certify that have read this document and the information is accurate and complete. understand that any person who knowingly files a statement of claim containing any false or misleading information may be subject to criminal and civil penalties. ignature of Beneficiary Print ame ertification re you a U.. itizen: o (f o - Form W-8 required) Provide other work D if available Under penalty of perjury, certify that: 1. he number shown on this form is my correct ocial ecurity/axpayer dentification number; and 2. am not subject to backup withholding because: (a) am exempt from backup withholding, or (b) have not been notified by the nternal evenue ervice () that am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the notified me that am no longer subject to backup withholding; and 3. am a U.. citizen or other U.. person. : ertification nstructions You must cross out item 2 above if you have been notified by the that you are currently subject to backup withholding because of under reporting interest or dividends on your tax return. he does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. f you fail to certify, we may be required to withhold federal and state tax. Your ignature Print ame Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 3 of Z of 14 (11/15)

7 GUD L Group dministration H- DBLY (D) L Forms should be completed by submitting a D claim after the employee s last day worked. ompleted forms should be faxed or mailed to Dearborn ational at the address shown on the claim form. Please ote: f you have Voluntary D coverage with Dearborn ational, please submit the most current enrollment form your employee has completed, as well as any recent change forms that have been completed during past annual enrollment periods. ee sample on page 7 as a guide to completing this form. (ote: nly sections of the actual form are displayed here.) LG- DBLY (LD) L f your company has an D plan with Dearborn ational and the D claim form has already been completed and submitted to Dearborn ational, the claimant may not be required to submit a LD claim form. Dearborn ational will contact the claimant if additional information is required. f your company does not have an D plan with Dearborn ational, the LD claim form should be submitted approximately 6 to 8 weeks prior to the end of the elimination period. ompleted claim forms should be faxed or mailed to Dearborn ational at the address shown on the claim form. ee samples on page 7 (D) and page 10 (LD). (ote: nly sections of the actual form are displayed here.) 7 of 14 (11/15)

8 GUD L Group dministration D L F Phone umber: (877) Fax: (877) Group hort-erm Disability laim Form eturn to Dearborn ational at: ttention: laim Department P.. Box 7071 Downers Grove, L : ll portions of this form package must be completed to avoid undue delay in processing claimant's request for benefits. F L - mployer nstructions omplete the following when an employee will be out of work longer than the D elimination period:. omplete the mployer's eport of laim in full; B. Give claim form to claimant for completion; and. equest copy of awards from other sources of benefits: ocial ecurity, Workers' ompensation, retirement, state disability, and others. When claimant returns the form to you:. ttach: Job description (detailed duties) Proof of enrollment (only for contributory coverage) Documentation of earnings if other than straight salary f Workers' ompensation claim filed, include copy of First eport of ccident and the decision B. eturn, together with all attachments, to Dearborn ational Life nsurance ompany (Dearborn ational) at the address shown above. PPL F D BF - mployee 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. Give 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 a copy of ocial ecurity and other income entitlement awards; and B. eturn to your employer. lectronic Funds ransfer (F) uthorization f you are eligible for weekly benefits, and wish to receive benefits via direct deposit, complete the attached form and return as indicated. PPL F D BF - Physician nstructions s soon as the claimant gives you this form:. omplete the P on page 4 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 P WH KWGLY D WH DFUD Y U PY H P FL PPL F U F L G Y LLY FL F L F H PUP F LDG, F G Y F L H FUDUL U, WHH D UBJ UH P L D VL PL. (ot enforceable in regon or Virginia.) Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 1 of Z4676 L 8 of 14 (11/15)

9 GUD L Group dministration D L F Phone umber: (877) Fax: (877) Group hort-erm Disability laim Form eturn to Dearborn ational at: ttention: laim Department P.. Box 7071 Downers Grove, L GUP UB PL YP F L BG UBD hort-erm Disability Voluntary D pecific Disease Benefit L (Please Print) laimant ame (Last) (First) () ocial ecurity # Height Weight Birth ddress ity tate Zip Phone umber -mail ame of mployer ccupation aiden ame lias ame re you filing a claim for this disability under the Workers ompensation ct: re you filing a claim for this disability under the ocial ecurity ct: Describe other income you are receiving: Y YP * U ocial ecurity (disability or retirement) tate disability etirement (normal, early or disability) Workers' ompensation Group disability benefits ther (describe) * Please send a copy of your award letter, if applicable. o o D BF BG D BF D F U 1. of accident or beginning of sickness last worked 2. ature of injury or illness 3. f injury, describe how, when and where occurred 4. Have you ever had same or similar illness: o f yes, give dates: From o 5. ame of hospital(s) s confined: From o ddress of hospital(s) 6. ame and address of Doctor(s) s of treatment 7. Between what dates were you unable to perform any duties From o From o G D UHZ: authorize my employer to disclose all information necessary to process my claim to Dearborn ational Life nsurance ompany (Dearborn ational). hereby authorize any medical professional, hospital, medical facility, medical provider, clinic, pharmacy, Government gency, nsurance ompany or any overed ntity or Health Plan as defined by the Health nsurance Portability and ccountability ct of 1996 (HP) to disclose to Dearborn ational's claim department or its authorized representative(s) 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, HV (D Virus) or other sexually transmitted diseases. further authorize Dearborn ational to disclose the information obtained in the consideration of my claim for insurance to its reinsurers. his authorization shall expire on the date that receive notice of Dearborn ational's final decision on my claim. understand and agree that: may revoke this authorization at any time, but that 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 HP Privacy ule; should retain a duplicate copy of this authorization for my own records.; photocopy of this authorization shall be as valid as the original; as well as any other person authorized to act on my behalf or my personal representative, acknowledge the right upon request to obtain a true 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. Y P WH KWGLY D WH DFUD Y U PY H P FL PPL F U F L G Y LLY FL F L F H PUP F LDG, F G Y F L H FUDUL U, WHH D UBJ UH P L D VL PL. (ot enforceable in regon or Virginia.) ignature of mployee Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 2 of Z4676 L 9 of 14 (11/15)

10 GUD L Group dministration D L F Phone umber: (877) Fax: (877) PLY Group hort-erm Disability laim Form eturn to Dearborn ational at: ttention: laim Department P.. Box 7071 Downers Grove, L mployee ame (Last) (First) () ocial ecurity # of Hire ffective of nsurance mployer ame mployer Group umber mployer ddress ity tate Zip Phone umber mployer -mail ddress Last Day Worked F eturned F Base alary P P Workers' omp laim Filed for this LF DD LY: mount of Disability: o weekly disability benefit mployee ccupation Hourly onthly lass Hours worked per week Weekly laimant received: alary continuation through Vacation through ick Pay through Does the mployee contribute towards the cost of this D insurance: yes no f ",": Pre-ax Post-ax f "Post-tax," % premium dollars paid by employer, % paid by claimant. ee Publication 15- mployer's upplemental ax Guide, ection 6, ick Pay eporting and/or evenue uling for more information on calculating the taxable percentage. ignature itle elephone DG PHY laimant's ame (Last) ddress ity (First) (ust be completed in full at the patient s expense) () ge ale tate Zip Female 1. ature and origin of sickness injury Diagnosis (describe complications, if any) 2. symptoms first appeared or date of accident patient first consulted you for this condition 3. s the condition work related yes 4. Describe any other disease or complications effecting present condition 5. and surgical procedure(s), if any no 6. f maternity give estimated or actual date of delivery Vaginal -section 7. Please give dates of treatment other than surgical 8. Please give hospital name & address with dates of confinement From o npatient utpatient Hospital name Hospital address 9. Has patient ever had same or similar condition yes no (f yes, state when and describe) 10. s patient still under your care yes no (f discharged give date and degree of recovery) 11. s patient under the care of another physician yes no (f yes, provide name, address and phone # of physician) 12. Patient was or will be continuously disabled (unable to work) n his/her own occupation From o n his/her own occupation From Patient can return to work Full time Part time n estrictions 13. Patient was or will be partially disabled From hrough 14. n your opinion, is patient candidate for rehabilitation 15. f patient is diagnosed as terminal, is life expecatncy emarks o return to own occupation 6 months or less For another occupation 12 months or less ther no o Physician ame Phone Fax Physician ignature ddress ity tate Zip pecialty: FP P& euro rtho BG Psych ther Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 3 of Z4676 L 10 of 14 (11/15)

11 GUD L Group dministration L P L Y H B F F mployer eport f laim o be ompleted by mployer 1. mployee ame (Last) (First) (..) 2. ocial ecurity o. 3. of Birth 4. ddress ity tate Zip ode 5. nsurance lass 6. mployee of Hire 9. ccupation at ime Last Worked (attach job description) 7. mployee Became nsured for LD 10. Work chedule at ime Last Worked o. of Days o. of Days Per Week Per Day 8. mployee was actually last present at work 11. eason for stopping: 12. Has mployee eturned to Work: o ickness Granted L Laid ff esigned f : Part-ime Full-ime etired Dismissed ther Vacation 13. How is mployee Paid: 14 mployee's Basic onthly arnings traight alary Hourly ommissions nly alary & ommission alary & Bonus LD Benefit Does the mployee contribute towards the cost of this LD insurance: yes no f ",": Pre-ax Post-ax f "Post-tax," % premium dollars paid by employer, % paid by claimant. ee Publication 15- mployer's upplemental ax Guide, ection 6, ick Pay eporting and/or evenue uling for more information on calculating the taxable percentage. 16. Has the nsured eceived ther Disability Payments ince ime Last Worked alary ontinuance: nsured hort erm Disability: alary ontinuance: o Wkly. mt. Benefits ease 17. Did laim esult From Job ctivity: o xplain Wkly. mt. o Benefits ease Wkly. mt. 18. Has Workers' ompensation claim been filed: (nclose copy of 1st report of accident o Pending 20. s mployee overed by mployer ponsored etirement Plan: o Denied (nclose copy of denial) 22. s mployee or will mployee be ligible for a Disability or etirement Pension: f : Disability onthly mt. o etirement ther ommence of Benefits 23. mployer ame (association and policyholder, if other) Benefits ease Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 2 of _13 Z4643L o 19. Workers' omp. Weekly mount: 21. Does etirement Plan ontain a Disability Provision: o (Please nclose opy of ummary Plan Description) : f any Portion of this Pension Benefit is ttributable to the mployee's ontribution, Please Provide Details ncluding the Percentage of His/Her ontribution to the otal ontribution. 26. ddress 27. mployer (axpayer).d. umber () 28. Public mployer ocial ecurity o. 69 ity 24. elephone o. 25. Group Policy o. tate Zip ode 29. ame of Person ompleting this Form (Printed) 30. ignature of uthorized nsurance epresentative itle LD L F 11 of 14 (11/15)

12 GUD L Group dministration LD L F 1. Full ame (Last) (First) (..) 2. aiden ame 3. lias ame mployee laim tatement o be ompleted by mployee 4. ocial ecurity o. L 5. Phone umber 6. of Birth 7. Height - ft. in. ity tate Zip ode 8. Weight 9. ex ale lbs. Female 11. arital tatus ingle Widowed arried Divorced 10. ddress 12. pouse's of Birth First ame 14. umber of hildren (Under age 19) 15. List ames and DB of unmarried children in high school 13. s pouse mployed o P L Y L H Y H 16. mployer ame 17. Group Policy o. 18. ccupation (List the duties of your occupation at the time of disability) 19. ccident or first noticed symptoms of illness on 20. have been unable to work due to the disability since 23. s Your ccident or llness elated to Your ccupation: o xplain 21. returned to work on a part-time basis on 22. returned to work on a full-time basis on 24. Have You or do You ntend to File a Workers' omp laim: o 25. Describe How and Where the ccident ccurred or Describe the nset and ature of Your llness 26. You Were First reated for llness/njury 28. Have You had the ame or imilar ondition Before 27. reated By Hospital Doctor 29. reated By Hospital ame treet ddress ity tate Zip ame treet ddress ity tate Zip ame treet ddress ity tate Zip Doctor ame treet ddress ity tate Zip 30. Describe ther ncome You are eceiving mount Began erm. o ocial ecurity (disability or retirement) o tate Disability o etirement (normal, early, or disability) o Workers' ompensation o Group Disability Benefits o ther (describe) 31. Have You pplied, or do You Plan to pply for Benefits Described bove: o ype pplication Filed ype pplication Filed 32. f Your equest for Benefits is pproved, do You want Us to Withhold mounts from each Benefit for Federal ncome ax Purposes: o f, Please omplete and ttach Form W4. UHZ: authorize any medical professional or provider, hospital, medical facility, clinic, pharmacy, Government 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, HV (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 HP Privacy 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 Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 3 of _13 Z4643L 12 of 14 (11/15)

13 GUD L Group dministration LD L F ttending Physician tatement ame of Patient (Last) (First) (..) of Birth *Please submit bill for records with this claim. H Y D G P G D P P G H B K (a) When did symptoms first appear or accident happen (b) patient ceased work because of disability (c) Has patient ever had same or similar condition o f, state when and describe (d) s condition due to injury or sickness (e) ames and addresses of other treating physicians arising out of patient's employment o Unknown (a) Diagnosis (including complications) Please submit all office notes regarding this condition* (c) bjective findings (including current x-rays, KG's, laboratory data and any clinical findings) (a) of first visit (b) of last visit (c) Frequency Weekly (d) ature of treatment (including surgery and medications prescribed, if any) (a) Has patient ecovered mproved (b) s patient mbulatory (b) ubjective symptoms onthly Unchanged etrogressed Bed onfined Hospital confined (c) Has patient been hospital confined o onfined from through f, yes, give hospital name and address (a) Functional capacity (merican Heart ss'n.) lass 1 (no limitation) lass 2 (slight limitation) lass 3 (marked limitation) lass 4 (complete limitation) (b) Blood Pressure (last visit) ther House onfined systolic/diastolic (a) Physical impairments (*as defined in Federal Dictionary of ccupational itles) lass 1 - o limitation of functional capacity; capable of heavy work* o restrictions (0-10%) lass 2 - edium manual activity* (15-30%) lass 3 - light limitation of functional capacity; capable of light work* (35-55%) lass 4 - oderate limitation of functional capacity; capable of clerical/administrative (sedentary*) activity (60-70%) lass 5 - evere limitation of functional capacity; incapable of minimum (sedentary*) activity (75-100%) emarks (b) ental mpairments (if applicable) (a) Please define "stress" as it applies to this claimant (b) What stress and problems in interpersonal relations has claimant had on job lass 1 - Patient is able to function under stress and engage in interpersonal relations (no limitations) lass 2 - Patient is able to function in most stress situations and engage in most interpersonal relations (slight limitations) lass 3 - Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations) lass 4 - Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations) lass 5 - Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations) emarks (a) s patient now totally disabled Patient's job: o (b) patient became disabled due to present illness ny other work: o (c) When do you expect a fundamental or marked change in the future: 1 o 1-3 o 3-6 o ever pplies o: Patient's job ther Work (a) s patient a suitable candidate Patient's job: for occupational rehabilitation ny other work: (c) When could trial employment commence (Limitations, herapy, etc.) o o Patient's job: (b) an present job be modified to allow for handling with impairment: o Full-time Part-time ame (ttending Physician) (Last) (First) Degree elephone ddress ity tate Zip Fax# Patient's job: Full-time Part-time ignature Products and services marketed under the Dearborn ational brand and the star logo are underwritten and/or provided by Dearborn ational Life nsurance ompany (Downers Grove, L) in all states (excluding ew York), the District of olumbia, the United tates Virgin slands, the British Virgin slands, Guam and Puerto ico. Page 4 of _13 Z4643L 13 of 14 (11/15)

14 GUD L Group dministration X PG GUDL nternal evenue ervice () Publication 15- requires Dearborn ational to report to employers the benefits paid and taxes withheld for their employees. s a policyholder, you are responsible for matching the employee s portion of social security and medicare taxes (F) on all taxable D and LD benefits as well as associated W-2 reporting. Paid claims reports will be sent weekly, quarterly and annually. XBLY F DBLY BF D and LD benefits may be considered taxable income. he taxability of these benefits is determined by who pays the premium and how premium is paid. f the employee pays any portion of the premium on a post-tax basis, the portion of their benefit attributable to their percentage of premium contribution is not taxable. f any portion of the premium is paid by the employee on a pre-tax basis, the portion of their benefit attributable to their percentage of premium contribution is taxable. ny portion of their benefit attributable to their employer s contribution is taxable. f the benefit is taxable, Dearborn ational is required to withhold social security and medicare taxes (F); however, federal income tax (F) is not required to be withheld. Dearborn ational will withhold F by request. Form W4- should be submitted with the claim form to Dearborn ational if F withholding is requested by your employee. Y-D X PG For those employers whose group insurance plan includes D or LD insurance, Dearborn ational can also prepare and issue a W-2 for each insured receiving disability payments. Groups must be fully insured. signed W-2 agreement is required. Please refer to the agreement (found on our website) for specific time limits that must be met. F DB LF nsurance ompany Paid Disability laims F/F Withholding eport for: 1/1/2008-3/31/2008 Policyholder: PL GUP Policy #: GFZ00001/1 G PL GUP DPD LVG laim # LB heck # GUL LD GUL LD GUL LD Benefit Period Pay ype Pay Payee Pmt mt ed Fed tate ther heck mt laimant: U DVD B JH : /08/07-01/08/08 01/05/08-02/02/08 02/02/08-03/01/08 HK 1/22/08 U DVD B JH HK 2/11/08 U DVD B JH HK 3/6/08 U DVD B JH ertificate Holder otals: laimant: DL P H : GUL D /03/07-12/24/ GUL D GUL D GUL D GUL D GUL D HK 1/11/08 DL P H ertificate Holder otals: laimant: Y BG WGH : /12/07-02/06/08 02/06/08-02/20/08 02/20/08-03/05/08 03/05/08-03/19/08 03/19/08-04/02/08 Division #: 1 Dept: HK 2/1/08 Y BG WGH HK 2/15/08 Y BG WGH HK 3/3/08 Y BG WGH HK 3/14/08 Y BG WGH HK 3/31/08 Y BG WGH ertificate Holder otals: Group otals: 11, , of 14 (11/15)