Instructions Disability Claim 1. Complete Part 1, the Insured Information/Claimant Statement and read and sign the Certification. The Certification will be used to obtain the information needed to process your claim. Failure to complete this section will result in a processing delay. 2. Have your employer complete Part 2, the Employer s Statement. (Do not complete this section yourself.) 3. Have your current treating physician complete Part 3, the Attending Physician Statement. (Do not complete this section yourself.) 4. If you are filing during the first year of coverage (based on your coverage effective date), the claimant is subject to a pre-existing condition investigation. 5. Return all pages of the document to as noted above (Employer and Physician statements can be sent separately, but we cannot process your claim until we receive the complete document.) 6. Waiver of premium is automatically processed for Disability claimants after being continuously disabled for 30 days. Part 1 Insured Information/Claimant Statement Insured Name Social Security Number Member ID Birth Gender M Insured Address City State ZIP Code Telephone Number F Group/Company Name Policy Number Occupation the symptoms first appeared Describe the onset and nature of your disability. Is your disability related to your occupation? Yes No Doctor(s) treated or referred by within the last year (Attach additional sheets, as necessary.) Has a Workers Compensation claim been filed? Yes No If yes, what is the status of the claim? Approved Pending Denied Name Address City State ZIP Code Phone Number If hospitalized with in the last year (Attach additional sheets, as necessary.) Name of Facility Address City State ZIP Code Phone Number If hospitalized, provide dates From Through s you were considered totally disabled From Through s you were considered partially disabled From Through you returned or expect to return to work Full-time Part-time HG0962 (R8/09) Part 1 Page 1
Fraud Notice (Please read carefully) Any person who knowingly and with intent to defraud or deceive any insurance company submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties, depending upon state law. In Arkansas, 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. For your protection, California 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 a state prison. In the District of Columbia, 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. In 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. In Kentucky, any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. Any application for insurance in writing by the applicant shall be altered solely by the applicant or by his written consent; except that insertions may be made by the insurer for administrative purposes only in such manner as to indicate clearly that such insertions are not to be ascribed to the applicant. In Maryland, any person who knowingly and 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. In Ohio, 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 In 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. In 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 Washington, 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. Certification I have checked the answers I have provided, and certify to the best of my knowledge and belief that they are correct. I agree that any personally identifiable health information is protected by the Health Insurance Portability and Accountability Act of 1996, if applicable, as well as other Federal and State privacy laws. In accordance with those laws, may use and disclose Protected Health Information for treatment, payment and health care operations as described in its Notice of Privacy Practices or other applicable Privacy Policy. I certify that the information provided on this claim form is correct and complete. I agree that a photographic copy of this certification shall be as valid as the original. Insured Signature Insured/Authorized Representative Signature Telephone Number HG0962 (R8/09) Part 1 Page 2
Part 2 Employer s Statement (to be completed by your Benefits Department) Employee s Name Employee ID/Social Security Number Birth of Hire Occupation at time last worked (attach job description) employee was actually last present at work Work schedule at time last worked s employee did not work at all s employee worked less than full-time hours Number of Days/Week Number of Hours/Day From Through From Through employee returned to full-time work or light duty/part-time Did the claim result from job activity? Yes No If yes, attach first report of injury. If the employee has not returned, is light duty available? Yes No Has a Workers Compensation claim been filed? Yes No If yes, what is the status of the claim? Approved Pending Denied Workers Compensation weekly amount: $ Has the employee received any other income as a result of the disability? Yes No Salary continuance, sick pay or vacation? From : To : Other type: From : To : Is any portion of the employee s policy paid for by the Employer? Yes No Authorized Employer s Signature Is the employee s policy paid for with pre-tax dollars (Section 125)? Yes No What are the employee s basic monthly earnings? Company Name Name/Title of Person Completing Form Phone Number Company Address City State ZIP Code Signature of Authorized Employer Representative HG0962 (R8/09) Part 2 Page 1
Part 3 Attending Physician s Statement (to be completed by your current treating physician) Patient s Name Birth When did the symptoms first appear or accident occur? patient ceased work because of disability: Has the patient ever had the same or a similar condition? Yes No If yes, provide date: Is the disabling condition a result of the patient s employment? Yes No If yes, date incident occurred: Names and addresses of referring or other treating physician(s) (attach additional sheets, as necessary) Name Address City State ZIP Code Phone Number Diagnosis Diagnosis, including complications ICD Code Subjective Symptoms If pregnant (EDC) Objective findings, including current x-rays, EKGs, laboratory data and any clinical findings Treatment first treated for this condition last treated for this condition Frequency Weekly Monthly Other: Nature of treatment and medications prescribed, if any: Did the patient have surgery? Yes No If yes, provide operative report Prognosis The patient has: Recovered Improved Remained unchanged Retrogressed The patient is: Ambulatory House Confined Bed Confined Hospital Confined If the patient has been confined to a hospital, provide dates and hospital name and address below: Hospital Confined: From: To: Hospital Name Address City State ZIP Code Is the patient now totally disabled? Patient s Job: Yes No Any Other Work: Yes No patient became totally disabled due to present condition: HG0962 (R8/09) Part 3 Page 1
When do you expect a fundamental or marked change in the patient s condition? 1 Month 1-3 Months 3-6 Months 6-9 Months 9-12 Months Never When do you anticipate a return to work? Impairments Physical Impairments (as defined in the Federal Dictionary of Occupational Titles) Class 1: No limitation of functional capacity; capable of heavy work. No restrictions (0-10%). Class 2: Medium manual activity (15-30%). Class 3: Slight limitation of functional capacity; capable of light work (35-55%). Class 4: Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity (60-70%). Class 5: Severe limitation of functional capacity; incapable of minimum (sedentary) activity (75-100%). Restrictions and limitations, i.e., what specific activities is the patient incapable of performing? Rehabilitation Is the patient a suitable candidate for occupational rehabilitation? Patient s Job: Yes No Any Other Work: Yes No Can the patient s present job be modified to allow for handling with impairments? Yes No If yes, how? When could a trial employment commence? (Patient s Job): Full-time Part-time Light Duty (Patient s Modified Job): Full-time Part-time Light Duty Remarks Any additional comments regarding the patient s condition Certification I hereby certify that the above described information is based upon reasonable medical probability and is true and correct to the best of my knowledge and belief. Name (please print) Phone Number Address City State ZIP Code Degree/Specialty Medical ID Number Signature of Physician HG0962 (R8/09) Part 3 Page 2