Long Term Disability Claim Form Employer: Group No: CL /AA GA 0906
To file an application for Long Term Disability benefits, please follow the instructions below to avoid unnecessary delays. This claim form requests information that is necessary for the speedy and accurate administration of your claim. If it is not completed in full, determination of benefits will be delayed until all required information has been received. If a question does not apply, or information is not available, please write NA (not applicable) in those spaces. There are five (5) primary sections to be completed in this form: Section 1: Section 2: Section 3: Section 4: Section 5: Authorization and Disclosures You (the employee) must fully complete the Authorization, page 2. This will allow us to secure additional information (if necessary) to make a decision on your claim. Employee s Statement Fully complete the section To Be Completed By Employee, page 3. Employer s Statement Have the employer fully complete the section To Be Completed By Employer, page 4. Job Analysis Have your supervisor fully complete the section To Be Completed By Employee s Supervisor, page 5. Physician s Statement Have your attending physician complete the section To Be Completed By Physician, page 7. Please complete the top line with your name, date of birth and social security number before giving the form to your physician. When all sections of this form have been completed, send it to us at the above address by mail or fax. It is the responsibility of you and your employer to inform us of any scheduled or actual return to work date as soon as possible. If an overpayment should occur on your claim, the amount of the overpayment must be returned to us. Page 1
Authorization and Disclosures Section 1: To Be Completed By Employee The following authorization will be used to obtain additional information (if necessary) concerning this claim. Authorization for Release of Information Persons or Institutions: This authorizes you to give, its representatives, or persons performing business or legal services on behalf of Anthem Life any information, data or records you have regarding my medical history and treatment (including records pertaining to psychiatric, drug or alcohol use, and any medical condition I may now have or have had), and any information, data or records regarding my Social Security, FICA earnings history, Workers Compensation, state disability, pension, credit, financial, earnings and employment history needed to evaluate my claim for disability benefits. I understand that any information obtained pursuant to this authorization will be used only to evaluate my claim and may be transferred to any organization or person employed by or representing Anthem Life to assist with this purpose. This authorization is valid during the pendency of my claim. I understand that I have the right to request and receive a copy of this authorization. A photocopy of this authorization is as valid as the original. Name (please print) X Signature The laws of some states require us to provide you with the following information: Any person who knowingly, and with intent to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information, is guilty of a felony, and may be subject to imprisonment, fines, and civil damages. California: 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: 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 damages. 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. Florida: 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. Kentucky: 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 act, which is a crime. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New York: 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 five thousand dollars and the stated value of the claim for each violation. Pennsylvania: 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. In addition, submission of false information in connection with this claim form may also constitute a crime under federal laws. Anthem Life will pursue any appropriate legal remedies in the event of insurance fraud, including prosecuting under federal mail fraud, federal wire fraud, and/or the Federal Racketeer Influenced and Corrupt Organizations Act statutes. Any false statements made herein may be reported to state and federal tax and regulatory authorities as is appropriate. Page 2
Employee s Statement Section 2: To Be Completed By Employee (Please Print) If claim form is not completed in full, determination of benefits will be delayed until all required information has been received. Write NA in non-applicable sections. 1 Employee Name 2 Social Security No. Street/Box/Apt. 3 Phone No. ( ) City, State, Zip 4 of Birth 5 Height 6 Weight 7 Male Female 8 Employer Name 9 Occupation 10 List Occupation Duties 11 of accident or 12 Last Day Worked 13 Are you unable to work due to? (check one) date of first symptoms Injury Illness Pregnancy 14 you Returned to Work Full Time Part Time 15 If you have not returned to work, when do you expect to return? Full Time Part Time 16 Describe in detail, when, where and how accident occurred, or nature of disability and first symptoms 17 Is your accident or illness related to your occupation? Yes No If yes, explain what happened: 18 If work related, have you filed a Workers Compensation Claim? Yes No If no, do you intend to? Yes No If no, explain why not: 19 When were you first treated for your illness or accident? Hospital (s) Doctor (s) 20 Have you ever had same or similar condition in the past? Yes No If yes, list name and address of Hospital/Doctor Hospital (s) Doctor (s) 21 Are you receiving? (check those benefits you are receiving) Workers Compensation Amount $ Begin End Short Term Disability Amount $ Begin End Social Security Amount $ Begin End Unemployment Amount $ Begin End State Disability Amount $ Begin End Other (Indiv. or Group)* Amount $ Begin End Canadian Pension Plan Amount $ Begin End Auto Ins. Wage Replacement* Amount $ Begin End *If yes, give name and address of Insurer(s) 22 23 If married, spouse s name and Social Security No. 24 Spouse of Birth Single Married Divorced Widowed 25 Is Spouse Employed? 26 List Children under age 25 (Names and of Birth) Yes No 27 If benefits are approved, do you want the minimum $87.00 per month withheld from your check for Federal Income Tax purposes? Yes No If you want more withheld, please state dollar amount you want withheld $ The above statements are true and complete to the best of my knowledge and belief. Your signature is required for benefit consideration. SignatureX Page 3
Employer s Statement Section 3: To Be Completed By Employer (Please Print) If claim form is not completed in full, determination of benefits will be delayed until all required information has been received. Write NA in non-applicable sections. 1 Employee s Name 2 Employee Number (if applicable) 3 Social Security No. Street/Box/Apt. 4 of Birth City, State, Zip 5 Occupation 6 of Hire 7 Insurance Effective 8 Group No. 9 Multi-bill Code or Division No. 10 Policy Benefit Class 11 Employee s Work Schedule 12 How long has employee been in this job? Full Time Part Time Exempt Non-Exempt Seasonal 13 If not at work when Disability began (check status and provide date) 14 How was employee paid? (check appropriate box) Terminated Leave of Absence Other (Specify) Hourly Monthly Salary and Bonus Laid Off Sick Leave Weekly Commissions Commissions Only Vacation Resigned Biweekly Salaried Salary and Commissions 15 Salary Prior to Last Worked 16 Last Salary Increase 18 Has insured continued to be paid since they last worked? Base Monthly Wages $ 17 Employee Work Schedule at Time Last Worked Yes No W-2 Earnings $ Paid For Salary Continuation Overtime $ Days per week Vacation Commissions $ Hours per week Accrued Sick Leave Bonus $ Other 19 Last Worked 20 Hours Worked That Day 21 Has Employee Returned If yes, to Work? Yes No Full Time Part Time 22 Were there any changes to the employee s job responsibilities due to a medical condition before the employee stopped working? Yes No If yes, what were the changes and when were they made? 23 Does employee contribute toward the premium? Yes No If yes, Pre-Tax Post-Tax If Post-Tax % paid by employer % paid by employee 24 Do you have a pension plan? If yes, what type? Defined benefit 401(k) Other: Yes No Defined contribution Profit Sharing payment ended 25 I s the employee eligible for your pension plan? If eligible, does employee participate? What % does employee contribute? % Yes No If No, why? Yes No If No, why? If the employee participates, when is he or she eligible for benefits? Early Retirement Normal Retirement Disability Retirement 26 Employee is Eligible for If yes, Weekly or Benefits Yes No Monthly Amount Wk Mo Begin Salary Continuation $ Social Security $ Short Term Disability $ Unemployment $ State Disability $ Workers Compensation $ Has Workers Compensation If Workers Compensation has been denied, submit copy of denial with this claim. claim been filed? If Workers Compensation has been filed, submit copy of first report with this claim. Through 27 Name/ of employee s medical insurance carrier or HMO (Provide policy or ID No.) Name/ of Workers Compensation Carrier 28 Does your company have a rehire or return to work policy for disabled employees? Yes No 29 Name of Employer Phone Fax ( ) ( (Street or Box) City State ) Zip Signature (The above statements are true and complete to the best of my knowledge) X Page 4
Job Analysis Section 4: To Be Completed By Employee s Supervisor 1 Employee Name 2 Social Security No. 3 Job Title 4 Does the employee perform supervisory functions? Yes No If yes, how many people are supervised? Describe job duties. 5 Check the items below that relate to the employee s job. Use these definitions for the frequency of occurrence: Relate to Others Occasionally means the person does the activity up to 33% of the time. Frequently means the person does the activity 34% to 66% of the time. Continuously means the person does the activity 67% to 100% of the time. Written and verbal communication Reasoning, math and language Makes independent judgements Occasionally Frequently Continuously 6 Which of the following describes the employee s working environment? Check all that apply: Unprotected heights Changes in temperature or humidity Exposure to dust, fumes and gases Being near moving machinery Driving automotive equipment Other hazards 7 Is the employee required to travel? Yes No If yes, complete the following information: How does the employee travel? (Automobile, plane, train, etc.) Where does the employee travel? What percent of the time does the employee travel? 8 Check the items below that relate to the employee s job and complete the information requested. Occasionally = 0% - 33% Frequently = 34% - 66% Continuously = 67% - 100% Activity Standing Walking Sitting Balancing Stooping Kneeling Crouching Crawling Reaching/working overhead Climbing: Stairs Number of Stairs: Ladders Height of Ladder: Pushing Pulling Lifting/carrying Frequency of Occurrence Occasionally Frequently Continuously Describe Activity Weight lbs. lbs. lbs. 9 Can the job be performed by alternating sitting and standing? Yes No 10 Does the job require using the feet to operate foot controls? Yes No If yes, on what type of equipment? 11 How important is good vision in the job? Page 5
12 What are the major tasks requiring use of one or both hands? One Hand Both Hands 13 Can the job be modified to accommodate the disability either temporarily or permanently? Yes No If yes, explain 14 Is it possible to offer the employee assistance in doing the job (through use of technology or personal assistance for example)? Yes No If yes, explain 15 Name of person completing this form Title Signature (The preceding statements are true and complete to the best of my knowledge) X Page 6
Physician s Statement Section 5: To Be Completed By Physician Patient Name of Birth Social Security No. Height Weight Blood Pressure (last visit) 1 Patient is/was unable to work due to: (check one) Injury Illness Pregnancy 2 Diagnosis (include complications and ICD 9) Complete this section for Normal Pregnancy, then go to item 25 3 What was LMP date? 4 What is the expected date of delivery? 5 First Treated 6 Last Treated Complete the following items for all conditions Except Normal Pregnancy. Enclose Office Notes and Test Results with this form. 7 When did symptoms first appear 8 you advised patient 9 Is condition due to injury or illness arising out or accident happen? to stop working of patient s employment? Yes No 10 Has patient ever had same or If yes, state when and describe similar condition? Yes No 11 of First Visit 12 of Last Visit 13 Frequency of Visits 14 Objective Findings (X-rays, EKGs, lab data and clinical findings) 15 Subjective Symptoms 16 Nature of Treatment (surgery, medications, etc.) Provide medication dosage and frequency 17 Names and addresses of other physicians 18 Has patient been hospitalized? If Yes, give name and address Yes No From to 19 Restrictions (what the patient SHOULD NOT do) 20 Limitations (what the patient CANNOT do) 21 Mental Impairment (if applicable) Provide 5 AXIS Diagnosis I II IV V III 22 If this is a cardiac condition, what is the functional capacity? Class 1 - No Limitation Class 3 - Marked Limitation (American Heart Association) Class 2 - Slight Limitation Class 4 - Complete Limitation 23 Has maximum medical improvement been achieved? Yes No If no, when do you expect a fundamental change? 1-2 months 3-4 months 5-6 months more than 6 months 24 If employer can accommodate patient s limitations and restrictions, is patient able to return to work? Yes No What date could employment begin 25 Physician Name (Please Print) Degree Specialty Phone ( ) Fax ( ) City State Zip Signature (No Stamp) X Tax ID No. Page 7