Fillable Disability Claim Form 3. The authorization to release (ASA College)

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Disability Claim Form 3. The authorization to release (ASA College)

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GP9725-57 Page 1 of 7 (Spanish SP121) 10/2014
Disability Claim Form
Administered by
Principal Life Insurance Company
Attn: Group Life and Disability Claims Department
Des Moines, Iowa 50392-0002
Employer Statement
Instructions
Please mail, FAX, or email this completed form to: Principal Life Insurance Company, Group Life & Disability Claims Department, Des Moines, IA 50392,
1-800-255-6609, dlsbdclaims@exchange.principal.com. Please call 1-800-245-1522 with questions on how to complete this form.
1. This form should be completed in its entirety by the employer, the employee/claimant and attending physician.
2. If you have any additional information you feel would help in the review of this claim, please attach to this form.
3. The authorization to release medical information (Page 7) must be completed for all claims and returned with the other sections.
Type and amount of coverage employee is enrolled for with Principal Life Insurance Company.
Life coverage during disability $
Short term disability $
Long term disability $
Does your employee have Long Term Disability coverage with another carrier?
yes
no
Employee’s name
I.D. number
Employee’s address
Phone number
Employee’s job title
Date in job
Please complete the job description questionnaire on page 2 and send a copy of your employee’s job description with this completed form.
Actual hours employee worked per week
Date of employment
Effective date of employee’s coverage
Date employee last worked
# of hours worked on date last worked
Percentage of premium paid by employer*
% If less than 100%, were premiums paid with employee’s pre-tax dollars? post tax?
*See Internal Revenue code Section 105(a) and Regulations thereunder.
Reason stopped working illness injury other Was coverage in force when disability began? yes no
Has employee returned to work? yes no If yes, give date returned
Number of hours
Is disability due to employment? yes no If yes, date filed for Worker’s Compensation
If approved, amount of compensation received $
(If Worker’s Compensation approved or denied, please attach a copy of the award or denial letter with this claim.)
Name and address of Worker’s Compensation carrier (if disability is work related):
Employee’s salary $
Salary eff date
hourly weekly monthly annually
For hourly employees: Are hours worked in excess of 40 per week considered overtime? yes no
If salary is not paid hourly, is this a base wage? yes no Does the employee earn any commissions or bonuses? yes no
Any owner/partner salary? If yes, please designate amt or %.
If employee not paid by a standard wage, explain how they are paid.
Did the claimant have prior STD coverage with another carrier while employed with you? yes no
If yes, date the coverage was effective and name of prior carrier. Effective date: Name:
Was salary continued after date last worked? yes no If yes, please provide date salary continuance will be paid thru:
/ /
If salary was continued, was the amount paid the same as salary reported? yes no If no, explain:
Please specify: salary continuance sick pay vacation PTO other
Is employee eligible for or paying into State Disability Income? yes no
If yes, amount received: $ Effective date:
Is employee receiving a pension benefit under a plan sponsored by you, the employer? yes no
If yes, amount received: $ Effective date:
Is employee receiving any income from other sources you are aware of? yes no
If yes, amount received: $ Effective date:
Type of income:
Employer name
Plan number
Unit number
Date
Signature
X
Title
Telephone number
FAX number
Email address
GP9725-57 Page 2 of 7 (Spanish SP121) 10/2014
Job Description Questionnaire
Principal Life has dedicated staff who are available to both employees and employers to assist and answer questions on return to work. Please visit
our website at http://www.principal.com/grouplh/return-to-work/index.htm. We will also be available to discuss the benefits of return to work for
you and your employee once the claim is filed.
Name: Job title:
1. A regular work day consists of hours a day, days a week.
In a regular work day, the employee’s job involves:
2. Sitting hours at one time. hours during a regular work day.
Standing hours at one time. hours during a regular work day.
Walking hours at one time. hours during a regular work day.
Never – not applicable Occasionally – up to 3 hours in an 8-hour day or 1-12 times per hour
Frequently – 3-6 hours in an 8-hour day or up to 12-60 times per hour Continuously – 6-8 hours in an 8-hour day or 60 times per hour
Never Occasionally Frequently Continuously
3. Lifting lbs. lbs. lbs.
Carrying lbs. lbs. lbs.
4. Hand Use N O F C N O F C
Simple grasping (left) Simple grasping (right)
Power grasping (left)
Power grasping (right)
Pushing & pulling (left)
Pushing & pulling (right)
Fine manipulation
Keyboarding
(not keyboarding)
w.p.m.
5. Reaching N O F C N O F C
At shoulder level Above shoulder level
At waist level
Below waist level
6. Positioning N O F C N O F C
Bends (waist level)
Twists (waist level)
Squats
Crawls
Kneels
Balancing
Climbs (ladders)
Climbs (stairs)
7. Using feet for repetitive movements as in left right both
operational functions:
yes no yes no yes no
8. Environment yes no If yes, please describe.
Unprotected heights
Being around moving machinery
Exposure to marked changes in temperature and humidity
Exposure to dust, fumes and gases
Uses vibrating equipment
Walks on uneven terrain
Travels for work (if yes, by what means and how often)
9. Technology yes no If yes, please describe.
Operate automotive equipment (truck, forklift, etc.)
Office equipment (computer, 10-key, FAX, etc.)
Computer knowledge (software, E-mail, internet, etc.)
10. Remarks (Please add any additional requirements.)
11. If the Attending Physician for the employee listed above releases him/her will you be able to:
Accommodate part time work? yes no possibly
Accommodate light duty work?
yes no possibly
Employer signature:
X
Title: Date:
Please print name: Phone number:
GP9725-57 Page 3 of 7 (Spanish SP121) 10/2014
Attending Physician’s Statement
This completed form may be faxed to Principal Life at 1-800-255-6609.
To Be Completed By Physician – Please include office notes and test results from date of disability to present.
The Genetic Information Nondiscrimination Act of 2008
(
GINA
)
prohibits emplo
y
ers and other entities covered b
y
GINA Title II from requestin
g
or
requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you not provide an
y
g
enetic
information when responding to this request for medical information.
Patient’s name Date of birth Social Security No.
Height Weight Blood Pressure (last visit)
1 Patient is/was unable to work due to :
Injury
Illness
Pregnancy
2 Diagnosis:
ICD-9 Diagnosis Code(s):
3 List any complications your patient is experiencing:
4 Objective Findings (X-rays, EKG’s, MRI results, lab data and clinical findings)
5 Subjective Symptoms
6 When did symptoms first appear or accident happen?
7 Is this condition due to injury or illness arising out of patient’s employment?
yes
no
8 Did this condition already exist and become exacerbated by employment? yes no
Please explain:
9 Is patient competent to endorse checks and direct the use of those proceeds?
yes
no
10 Date of first visit 11 Date of last visit 12 Date of next visit 13 Frequency of visits
14
Has your patient been hospitalized?
yes no
From: To: Hospital name/number:
15
Has your patient ever had the same or similar condition?
yes no
If yes, when
16 NATURE OF TREATMENT – Please specify all surgeries, medications AND dosage, therapy, and/or referrals.
Date of surgery
Type of surgery
CPT-4 Codes
If the patient was referred to you or by you to another physician list the Physician’s name, address and phone number of the Physician:
17
PREGNANCY CLAIMS ONLY
What is the expected date of delivery? Date First Treated Date Last Treated Date of Delivery
Bed confined?
yes
no If yes, date began If patient has delivered, type of delivery
From: To:
Vaginal
C-Section
If complications are present prior to delivery, what complications is your patient experiencing?
GP9725-57 Page 4 of 7 (Spanish SP121) 10/2014
18 MENTAL IMPAIRMENT (if applicable) Provide 5 AXIS Diagnosis
I IV
II V
III
Please define “stress” as it applies to your patient:
Could your patient perform his/her job if it was for a different employer/supervisor?
yes no
19 CARDIAC (if applicable)
If this is a cardiac condition, what is the functional capacity? (American Heart Association) C1 C2 C3 C4
20 PHYSICAL IMPAIRMENT
Please provide the specific restrictions and limitations YOU have placed on your patient in the space provided below:
CONTINUOUSLY
(2/3 + of time)
FREQUENTLY
(1/3 – 2/3 of time)
OCCASIONALLY
(Up to 1/3 of time)
NEVER
Sit
Stand
Walk
Lift/Carry lbs. lbs. lbs. lbs.
Power Grasp
Fine Manipulation
Push/Pull
Keyboarding
Reach above shoulder level
Reach at waist level/below waist
Bend/Twist/Squat
Climb/Balance
Please provide any additional restrictions and limitations not specified above, including other factors that may affect employment activities:
PROGNOSIS:
Have you advised your patient to restrict employment activities?
yes
no
If yes, beginning on what date?
Have you discussed your patient’s job duties?
yes
no
Has your patient been released to return to work?
yes
no If yes, please provide date
If the employer can accommodate the patient’s limitations, do you support return to work at this time?
yes
no
If the employer can accommodate part-time work, do you support return to work at this time?
yes
no
If yes, how many hours per day?
If your patient has not been released to return to work, please provide an estimated return to work/recovery date.
Please explain if this date falls beyond the typical recovery time for this diagnosis.
21 Physician Name (Please Print) Degree
Specialty Phone Number FAX Number
Address City State Zip Code
Please provide a contact name for additional questions.
Signature (No Stamp) Tax ID Number NPI Number Date
X
GP9725-57 Page 5 of 7 (Spanish SP121) 10/2014
Employee Statement
The Employee Statement must be accompanied by the Authorization for Release of Personal Health and other Information found on page 7
Your name
Date of birth
Soc Sec #
Your home address
(Street) (City) (State) (ZIP code)
Home telephone number
Work telephone number
Gender male female
Cellular telephone number
Your email address
Date you became disabled Is disability due to accident illness Please describe accident in detail,
Including date, time and place of occurrence and include a copy of the accident report. If illness, nature of illness and date
If disability is the result of a motor vehicle accident, have you applied for or are you receiving No Fault/Auto Insurance Income Replacement benefits?
yes no If yes, date applied
Amt received $
Freq of pmts
Please include a copy of the police report and the auto agent’s carrier name, phone number and policy number:
Did disability result from employment? yes no Have you filed a Worker’s Compensation claim? yes no
If yes, date filed for Worker’s Compensation
If approved, amount received $
Freq of pmts
(If Worker’s Compensation is approved or denied, please attach a copy of the award or denial letter with this claim.)
Do you have other insurance with our company? yes no If yes, please list policy numbers:
Do you have other disability insurance with other companies? yes no If yes, provide the following:
Name of company Policy number/policy date Benefit amount received per month
Is the coverage listed above: Group coverage Individual coverage
Indicate if you have applied for or are receiving any of the following benefits, date applied and benefit amount if approved
(
please send cop
y
of award
letter or most recent benefit check stub.)
Type Date Income Began Amount Type Date Income Began Amount
Social Security
Disability/Retirement/Widows
State Disability
Social Security Early Retirement
Pension
Unemployment
Other Income
Describe which duties and activities you are unable to perform as a result of your disability and why:
List the number of hours you spend each day in the following activities while working:
Sitting
hrs/day Walking
hrs/day Lifting
hrs/day Average weight lifted
lbs
Standing
hrs/day Traveling
hrs/day Bending
hrs/day Maximum weight lifted
lbs
Names of doctors, practitioners and hospitals Telephone number Date confined/consulted Reason for confinement/consultation
I declare that all the above statements on this form are true and complete to the best of my knowledge.
X
(
Si
g
nature of emplo
y
ee
)
(
Date
)
I certify that I am a citizen of the following country:
X
Countr
(
Si
g
nature
)
(
Date
)
This completed form may be faxed to Principal Life at 1-800-255-6609.
GP9725-57 Page 6 of 7 (Spanish SP121) 10/2014
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.
Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for accident and health
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 such violation.
X
(Claimant’s Signature) (Date Signed)
Notice Requirements
Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a
false or deceptive statement, may be guilty of insurance fraud.
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination
thereof.
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly
presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
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 defraudin
g
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.
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.
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 insurance act, which is a
crime.
Louisiana: 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.
Maryland: Any person who knowingly or willfully 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 and confinement in prison.
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 Mexico: 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 civil fines and criminal penalties.
Ohio: Any person who, with intent to defraud or knowing that he or she 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.
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.
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.
Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the
company. Penalties include imprisonment, fines and denial of coverage.
Virginia: Any person who, with the intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
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.
GP9725-57 Page 7 of 7 (Spanish SP121) 10/2014
Authorization for Release
of Personal Health and
Other Information to
Principal Life Insurance Company
I authorize any physician, health care professional, hospital, clinic, laboratory, pharmacy, medical facility, health care provider, health plan and its
administrator, disability plan and its administrator, insurer, or any other entity subject to the Health Insurance Portability and Accountability Act of
1996 (HIPAA) that has provided treatment, service, or coverage to me to disclose my entire medical record to the Principal Life Insurance Company
(Principal Life), its agents, employees, insurance support organizations, reinsurers, and their representatives. This includes information on the
diagnosis and treatment of mental illness (excluding psychotherapy notes as defined under HIPAA) and the use of alcohol, drugs, and tobacco.
I understand my personal health information may be used or disclosed as set forth by this authorization. Protected health information includes
information created or received by Principal Life. Protected health information also includes but is not limited to: hospital records, treatment
records/office notes, alcohol or drug abuse treatment, consultation reports, workers' compensation information, diagnosis, prescriptions, test results,
vocational testing/counseling information, benefit information, claims information, demographic information, and claims payment information.
I understand that unless prohibited by state or federal law the protected health information is to be disclosed under this authorization so that Principal
Life may administer claims and determine or fulfill responsibility for coverage and provision of benefits, coordinate the provision of benefits under my
medical and disability coverages, and conduct other legally permissible activities that relate to any coverage I have or have applied for with Principal
Life.
Also, I authorize the Internal Revenue Service, Social Security Administration, any state taxing authority and any employer, former employer,
business associate or partners, insurance company, insurance support organization, Worker’s Compensation or vocational or rehabilitation counselor
or provider to give any information or record it has about me, my employment, employment history or income to Principal Life.
The following groups of persons employed or working for Principal Life may use my personal health and other information which is described above:
employees of the claim or legal departments and any other personnel of Principal Life, and its authorized representatives, and business associates
that perform functions or services that pertain to any coverage I have or have applied for with Principal Life. This includes, reinsuring companies,
persons or organizations performing business, legal or medical services related to the policy or claim, employer or former employer as needed to
perform fiduciary responsibility under any benefit plan and, when required by law, to any other public or private entity or person.
I understand any information disclosed under this authorization may no longer be covered by the privacy provisions of HIPAA and may be subject to
redisclosure. This authorization shall remain in force for 24 months following the date of my signature below, and a copy of this authorization is as
valid as the original. I understand that I have the right to revoke this authorization at any time. The request for revocation must be in writing and sent
to: Disability Claims, Life and Health Segment, Principal Life Insurance Company, Des Moines, IA 50392. I understand that a revocation is not
effective if Principal Life has relied on the protected health information disclosed to it or has a legal right to contest a claim under an insurance policy
or to contest the policy itself.
I understand that if I refuse to sign this authorization to release my complete medical record, Principal Life may not be able to process my application
for life or disability coverage, or if coverage has been issued, may not be able to make any such benefit payments. Upon your request, a copy of this
completed authorization will be provided to you. Any alteration of this form will not be accepted.
Claimant’s signature: Date: Incident #
Claimant’s full name: Date of birth:
Claimant’s address:
Telephone number: ( ) Can confidential messages be left at this number? yes no
OPTIONAL: I give you permission to speak with (full name) My spouse,
Domestic Partner, or ,concerning my claim during my disability.
If you are the representative of the member or the member's dependent
(
includin
g
a member actin
g
as a representative on a dependent's behalf
)
describe the
scope of your authority to act on the member's or dependent's behalf. Please include the proper documentation that attests to your ability to sign.
I certify that I am a citizen of the following country:
(
Countr
y)
(
Si
g
nature
)
(
Date
)
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Disability Claim Form 3. The authorization to release (ASA College)

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Completed 26 July 2020

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