Fillable APPLICATION FOR LONG TERM DISABILITY BENEFITS - EMPLOYEE (Equitable Life of Canada)

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APPLICATION FOR LONG TERM DISABILITY BENEFITS - EMPLOYEE (Equitable Life of Canada)

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Country of origin: CANADA
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Head Office
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
TF 1.800.722.6615 T 519.886.5210
www.equitable.ca
APPLICATION FOR LONG TERM DISABILITY BENEFITS -
EMPLOYEE
The purpose of this form is to enable us to process your claim and to assist us in evaluating the possibility of providing you with rehabilitation
assistance. Incomplete responses or missing information will cause delays in the assessment and handling of this file.
Employee Name:
(First) (Last)
Date of Birth:
Height:
Weight:
Marital Status: £ Single £ Married £ Common-law £ Separated/Divorced £ Widowed
Number of dependent children
whom you support:
List children’s
age(s):
Street
Address:
City:
Province:
Postal Code:
Residential No.: ( ) Cell No.: ( )
Group Policy No.: Certificate No.:/Social Insurance Number
(for taxable benefits only)
Employer:
Claim Number
(if known):
Job Title:
Length of Time
on this Job:
Length of Time
with the Employer:
Are you paid commissions, bonuses, overtime, car allowance? £ Yes £ No If “yes”, please describe and include the previous year’s
Notice of Assessment from Revenue Canada.
Please describe in chronological order the events leading up to your date of disability.
Is your claim for benefits due to a work related condition or a work related injury? £ Yes £ No
Date of Injury/Loss Location of accident (if applicable) Date of first treatment & name of provider
Are you still off work at the present time? £ Yes £ No If “no”, indicate Date Returned to Work:
Did you return to work and perform your regular full-time duties? Modified duties and or hours? Please describe:
Are you applying for or receiving benefits from provincial workers compensation plan? £ Yes £ No If “yes”, indicate below:
Date application submitted: Claim no:
Please attach all provincial workers compensation plan CPP correspondence.
Does your physician support this being a work related disability? £ Yes £ No If “no”, please explain:
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
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APPLICATION FOR LONG TERM DISABILITY BENEFITS WITH JOB PROFILE
Describe in detail what your job involves including shift work, weekends, supervisory responsibilities and whether job is dependent upon others or
whether their job depends on you.
List all types of machines, tools, office equipment and other special equipment you use to do your job.
Please describe how you are prevented from performing any of your job duties or using any of the above mentioned equipment?
What are the physical and cognitive activities required in this job?
Describe the work environment with regards to: presence of respiratory irritants, noise, humidity, heat, cold, hazards, etc.
Please mark off (x) in the applicable spaces below, those physical activities REQUIRED in YOUR job.
TOTAL HOURS PERFORMED DAILY
Physical Activities Required
Less than 1 1 - 2 3 - 4 5 - 6 7 - 8
LIFTING Under 10 lbs/(0.5-4.5 kg)
20 - 50 lbs/ (9.5-22.7 kg)
Over 50 lbs/ (22.8kg)
Over 50 lbs/ (22.8kg)
CARRYING Under 10 lbs/(0.5-4.5 kg)
10 - 20 lbs/ (5.0-9.1 kg)
20 - 50 lbs/ (9.5-22.7 kg)
Over 50 lbs/ (22.8kg)
REACHING Above shoulder height
At shoulder height
Below shoulder height
DRIVING
CLIMBING
KEYBOARDING
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
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APPLICATION FOR LONG TERM DISABILITY BENEFITS WITH JOB PROFILE
Explain how your condition prevents you from being in any of these positions for the duration required in your regular working hours:
Before you stopped working, did you change: £ Your job or duties £ Your hours of work £ Your attendance
If yes, explain if how your condition caused these changes and show the dates the changes were made.
In your normal workday, how long would you be in the following positions if you were doing your regular occupation?
Sitting _________hours Regular hours of work:
Standing _________hours Days of your Work Week: £
M
onday £ Tuesday £ Wednesday £ Thursday £ Friday £ Saturday £ Sunday
Walking _________hours First Break: from to
TOTAL _________hours Meal Break: from to
COGNITIVE DEMANDS - please check Yes or No in the applicable spaces below
Comprehension
£ Yes £ No Information processing £ Yes £ No
Visual perception
£ Yes £ No Memory £ Yes £ No
Attention
£ Yes £ No Other £ Yes £ No
Training required to perform your duties at this job (i.e. on the job, apprenticeship, formal education, etc.): _____________________
Total number of years you have been employed in this type of work: _______________
List any special or vocational courses required, including training time:
Additional Training: £
On the job training £ Apprenticeship £ Work-Study Program
What is your education level completed: £ Elementary
£ High School Grade £ 9 £ 10 £ 11 £ 12 £ 13
£ College
£ University
£ Other (specify):_________________________________________________________
List all diplomas, certificates, licenses, journeyperson cards, etc., you hold:
i) iv)
ii) v)
iii) vi)
List below all other kinds of work you have done for at least one or more years including military service if any:
Job Title Duties Worked from To
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
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APPLICATION FOR LONG TERM DISABILITY BENEFITS WITH JOB PROFILE
Do you expect to return to work at this job?
£ Yes £ No If “no”, give details below.
Date Expected to Return:
£ Part time £ Modified £ Regular
Are you currently involved in any other type of employment? £ Yes £ No If “yes”, please describe below.
i.e. part time employment elsewhere or home based business
ACTIVITIES OF DAILY LIVING
Has your physician told you to restrict your activities in any way? £ Yes £ No If “yes”, indicate the physician and describe the specific
restrictions on your activities.
Check any of the following which presently apply to you:
£ Confined in a hospital bed or other medical institution
£ Confined to bed or wheel chair at home
£ Not confined to bed or wheel chair but unable to go outside
£ Able to go outside only with the help of another person or device
£ Able to go outside without help
£ Unable to drive automobile: £ short distances
£ long distances
£ no valid license
Are your home duties, social activities or ability to care for your personal needs limited in any way? £ Yes £ No If “yes”, describe how
and why they are limited.
If this claim is a result of a motor vehicle accident, please provide us with all the correspondence you have had with your insurance company in
connection with this claim.
Date of accident:
Auto Insurance Company:
Contact Person:
Address: City Province Postal Code
Telephone: ( ) Claim No.:
What class of drivers license do you hold? What is the status of your drivers license?
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
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APPLICATION FOR LONG TERM DISABILITY BENEFITS WITH JOB PROFILE
Were you hospitalized due to this accident? £ Yes £ No If “yes”, please provide the following:
Name of hospital or institution and dates of admission & discharge.
MEDICAL INFORMATION
List the first and last name, address and telephone number of your Primary Care Physician.
Check here £ if you have no family physician.
Name: Speciality:
Street Address:
City: Province: Postal Code:
Telephone: ( )
How long have you attended
this physician’s office:
Date first seen: Date last seen: Frequency of appointments?
Reasons for appointments:
Type of Treatment Received:
Please indicate names of all other physicians you have attended in the past 3 years.
Name: Speciality:
Street Address:
City: Province: Postal Code:
Telephone: ( )
Date first seen: Date last seen: Frequency of appointments?
Reasons for appointments.:
Type of Treatment Received:
Name: Speciality:
Street Address:
City: Province: Postal Code:
Telephone: ( )
Date first seen: Date last seen: How often do you see him/her?
Reasons for appointments:
Type of Treatment Received:
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
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APPLICATION FOR LONG TERM DISABILITY BENEFITS WITH JOB PROFILE
Please indicate all other physicians you have attended in the past 3 years. (cont'd)
Name: Speciality:
Street Address:
City: Province: Postal Code:
Telephone: ( )
Date first seen: Date last seen: How often do you see him/her?
Reasons for visits:
Type of Treatment Received:
OTHER HEALTH CARE PROVIDERS
Have you been seen by other agencies for this condition related to this claim? £ Yes £ No If “yes”, complete the information requested below.
i.e. Dept. of Veteran Affairs, Vocational Rehabilitation, Welfare, Social Worker, Psychologist, Physiotherapist, Chiropractor, Masseuse)
Name the person or company that referred you:
Reason for Referral:
Name of Agency:
Contact Person:
Address: City Province Postal Code
Telephone: ( ) Claim No.:
Type of Treatment or Examination:
Dates of visits:
Name the person or company that referred you:
Reason for referral:
Name of Agency:
Contact Person:
Address: City Province Postal Code
Telephone: ( ) Claim No.:
Type of treatment or examination:
Dates of appointments:
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
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APPLICATION FOR LONG TERM DISABILITY BENEFITS WITH JOB PROFILE
Please indicate if you have applied or are in receipt of Benefits for any of the following.
SOURCE
SOURCE
NAME
DATE CLAIMED/
& STARTED AMOUNT FREQUENCY
Canada/Quebec Pension Plan
£ Retirement or £ Disability Benefits
£ No £ Yes
Provincial Workers Compensation Plan
£ No £ Yes
Group Life Insurance Income
£ No £ Yes
Retirement Income/
Social Security Administration
£ No £ Yes
War Veteran’s Disability Pension
£ No £ Yes
Income Replacement Benefits –
Motor Vehicle Accident
£ No £ Yes
Short Term Disability, Long Term Disability,
Creditor Disability or other disability
income through another insurance plan.
£ No £ Yes
Employment Insurance Canada:
£ No £ Yes
Other
£ No £ Yes
AUTHORIZATION & ACKNOWLEDGEMENT:
I certify that the information given on this form is true, correct and complete. For the purposes of underwriting, administration, claims processing
and adjudication with respect to the Group Policy and any supplementary forms/documents, I authorize The Equitable Life Insurance Company
of Canada (“Equitable”), its employees, representatives and service providers to use my personal information, and exchange such personal
information with reinsurers, insurers, investigative agencies, health care providers and facilities, and any other person or party whom I authorize.
For the above purposes, I authorize any physician, practitioner or other health care provider, hospital, clinic or other medical facility, pharmacy,
insurer, employer (past and present), provincial workers compensation plan, medical or benefit payment plan, service provider, and any other
institution, person or party that has any record or knowledge of my health relevant to this claim, to give to Equitable full particulars of such
information, including any prior medical history relevant to this claim and benefits. I transfer and assign to Equitable, and agree to pay and
refund to Equitable those disability and income replacement benefits which I receive or are receivable from all other sources, in accordance
with the provisions of the Group Policy, including without limitation, CPP, Worker’s Compensation, and other insurance policies. A photocopy or
electronic version of this acknowledgement shall be as valid as the original.
Date
(dd/mm/yyyy) Signature:
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
564(2020/06/30) Page 7 of 8
APPLICATION FOR LONG TERM DISABILITY BENEFITS WITH JOB PROFILE
Accept this as authorization for Equitable Life Insurance Company of Canada to deposit Group claim payments directly into my bank account.
Bank’s Name:
Bank’s Address:
Bank’s Phone No.: ( ) Bank’s Account No.:
area code
Institution Code: Branch Transit No.:
PLEASE ATTACH A VOID CHEQUE OR WE ARE UNABLE TO PROCESS YOUR REQUEST
Date Insured’s Signature
If you want Equitable Life to use electronic mail in addition to phone and regular mail for the purpose of communicating with you and to
provide you with information and documentation regarding your disability claim, please provide your e-mail address, and sign and date the
consent below. There is no obligation for you to provide this consent. We can continue to communicate with by phone and regular mail.
I consent to Equitable Life using electronic mail to communicate with me and to provide me with information and documentation regarding my
disability claim.
Email address:
Signature: Date:
PLEASE NOTE: Equitable Life cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may
be vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is
intercepted and misused.
You must notify The Equitable Life Insurance Company of Canada promptly if:
a. To avoid collections activity in the case of benefit overpayments or interruption in benefits,
b. Your medical condition improves so that you would be able to work, even though you have not yet returned to work.
c. You go to work whether as an employee or as a self-employed person.
d. You apply for benefits under any provincial workers compensation Law or Plan.
e. You apply for benefits under Canada/Quebec Pension Plan.
f. You apply for Retirement Benefits.
g. You are discharged from the hospital if you are now hospitalized.
h. You received increases in existing provincial workers compensation plan or War Veteran’s Disability Pension.
Upload the signed and completed form via www.
equitablehealth.ca using our secure Document Submission
Tool located under the My Resources tab. You can also fax
them to 1.888.505.4373 or mail them to:
Equitable Life of Canada
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
Please note: Equitable Life cannot ensure the privacy and
confidentiality of any information sent through the internet because
e-mail may be vulnerable to interception. As a result, Equitable
Life is not responsible for any loss or damages you may incur if
your information is intercepted and misused. If you would prefer
to submit your information by another means, please contact us at
1.800.265.4556.
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
564(2020/06/30) Page 8 of 8
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APPLICATION FOR LONG TERM DISABILITY BENEFITS - EMPLOYEE (Equitable Life of Canada)

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Completed 1 March 2021

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