Fillable Group/Association - Short Term Disability Benefits

Fill Online, Printable, Fillable, Blank Group/Association - Short Term Disability Benefits Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Group/Association - Short Term Disability Benefits

On average this form takes 32 minutes to complete

The Group/Association - Short Term Disability Benefits form is 4 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 122 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
500385 Rev. 01/2013
Group/Association - Short Term Disability Benefits
Life Insurance Company of North America
Connecticut General Life Insurance Company
Cigna Life Insurance Company of New York
Great-West Healthcare Administered by Cigna
DIVISION
Date:
REASONIF YES, DATE
NAME OF EMPLOYER / ASSOCIATION
EMPLOYER / ASSOCIATION
Life Insurance Company of North America
Connecticut General Life Insurance Company
Cigna Life Insurance Company of New York
Great-West Healthcare Administered by Cigna
Group/Association -
Short Term Disability Benefits
Print: Signature:
HAS EMPLOYEE/MEMBER BEEN TERMINATED?
IF YES, DATE
EMPLOYER’S / ADMINISTRATOR’S CERTIFICATION
PAID THRU DATEGROSS WEEKLY AMOUNT DATE BEGANBENEFIT
LAST DAY WORKED DATE RETURNED TO WORK PREMIUM PAID THROUGH DATE
% OF INSURED’S CONTRIBUTION
TO PREMIUM
# of Hours:
IF YES, DOES THIS LIFE INSURANCE POLICY CONTAIN A WAIVER OF PREMIUM PROVISION?
PLEASE LIST ALL BENEFITS THAT THE INSURED IS RECEIVING OR ELIGIBLE TO RECEIVE AS A RESULT OF HIS/HER DISABILITY (E.G. SALARY CONTINUANCE, SICK PAY,
STATE DISABILITY, WORKERS’ COMPENSATION, ETC.).
IS THIS INDIVIDUAL COVERED UNDER A LIFE INSURANCE POLICY PROVIDED BY A CIGNA UNDERWRITING COMPANY?
TO BE COMPLETED BY THE EMPLOYER / ADMINISTRATOR
NAME OF EMPLOYEE/ASSOCIATION MEMBER (Last Name) (Middle Initial) DATE OF BIRTH SEXSOCIAL SECURITY NO.(First Name)
Pre-Tax Basis
Post-Tax Basis
EMPLOYEE’S / MEMBER’S CONTRIBUTIONS WERE MADE ON:
If Yes, Attach Copy
WAS INSURANCE ISSUED ON THE BASIS OF A STATEMENT OF PHYSICAL CONDITION?
BASIC EARNINGS PER WEEK
PLEASE CHECK THE APPROPRIATE BLOCKS REGARDING THE INSURED’S EMPLOYMENT STATUS.
OCCUPATIONPOLICY NO.
( )
TELEPHONE #(Zip Code)(State)ADDRESS (Street) (City)
Hrs./wk
DATE OF LAST CHANGE IN EARNINGS DATE HIRED / MEMBER OF ASSOCIATION EFFECTIVE DATE OF INSURANCE
Page 2 of 5
HAS EMPLOYEE/MEMBER BEEN LAID OFF? REASON
500385 Rev. 01/2013
MAIL OR FAX TO:
TELEPHONE #(Zip Code)(State)ADDRESS (Street) (City)
( )
FRAUD WARNING: Any person who, knowingly and with intent to defraud any insurance company or other
person: (1) files an application for insurance or statement of claim containing any materially false information;
or (2) conceals for the purpose of misleading, information concerning any material fact thereto, commits a
fraudulent insurance act. For residents of the following states, please see the last page of this form: California,
Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New York, Oregon,
Pennsylvania, Rhode Island, Tennessee, Texas or Virginia.
FM
Part-time
Full-time
Hourly
SalariedManagementExempt Supervisory Union Local #
Non-UnionNon-SupervisoryNon-ManagementNon-Exempt
No Yes
No Yes
No
Yes
No Yes
No Yes
CLEAR FORM
Cigna
P.O. Box 709015
Dallas, TX 75370-9015
Facsimile: (800) 642-8553
Yes No
Yes No
Yes No
DATES OF SERVICE - INCLUDE DATE OF NEXT APPOINTMENT (IF PREVIOUS FORM SUBMITTED TO THIS CARRIER, YOU NEED SHOW ONLY DATES SINCE LAST REPORT).
DATE
REMARKS: WE ARE INTERESTED IN ANY INFORMATION THAT WOULD BE HELPFUL TO YOUR PATIENT FOR EVALUATION OF THIS CLAIM.
IF STILL DISABLED, DATE PATIENT SHOULD BE ABLE TO RETURN TO WORK.
DATE PERFORMED
INPATIENT
OUTPATIENT
THRUIF "YES", CONFINED FROM
HAS PATIENT BEEN HOSPITAL CONFINED?
DATE PATIENT FIRST CONSULTED YOU FOR THIS CONDITION.DATE SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED.
IS CONDITION DUE TO INJURY OR SICKNESS ARISING OUT OF
PATIENT’S EMPLOYMENT?
COMPLICATIONS
ESTIMATED DATE OF CONFINEMENT
APPROXIMATE DATE PREGNANCY COMMENCED
IF "YES", PLEASE PROVIDE THE FOLLOWING INFORMATION IF APPLICABLE.
Yes No
Yes No
DIAGNOSIS AND CONCURRENT CONDITIONS, INCLUDING ICD-9 OR DSM IV-TR CODE.
PLEASE LIST ALL BENEFITS YOU ARE RECEIVING OR ELIGIBLE TO RECEIVE UNDER ANY OTHER GROUP INSURANCE, GOVERNMENT PLAN OR AUTOMOBILE MANDATORY NO-FAULT COVERAGE.
PLEASE DESCRIBE YOUR JOB DUTIES IN DETAIL. WHAT PERCENT OF YOUR JOB REQUIRES PHYSICAL LABOR?
BENEFIT DATE BEGANGROSS WEEKLY AMOUNT PAID THRU DATE
TO BE COMPLETED BY ATTENDING PHYSICIAN
IS CONDITION DUE TO PREGNANCY?
DATE OF DELIVERY TYPE OF DELIVERY
PATIENT STILL UNDER YOUR CARE FOR
THIS CONDITION?
HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
IF "YES", WHEN AND DESCRIBE
NATURE OF SURGICAL PROCEDURE, IF ANY
PATIENT WAS CONTINUOUSLY TOTALLY DISABLED - (UNABLE TO WORK)
NAME AND ADDRESS OF HOSPITAL
From:
Thru:
PHYSICIAN’S NAME (PRINT)
SIGNATURE
ARE YOU COVERED UNDER A LIFE INSURANCE POLICY PROVIDED BY A CIGNA UNDERWRITING COMPANY?
IF YES, DOES THIS LIFE INSURANCE POLICY CONTAIN A WAIVER OF PREMIUM PROVISION?
TELEPHONEZIP CODESTATE OR PROVINCESTREET ADDRESS
TAX IDENTIFICATION NUMBERDEGREE SOCIAL SECURITY NUMBER
CITY OR TOWN
HAVE YOU HAD THE SAME OR SIMILAR CONDITION IN THE PAST? IF SO, PLEASE DESCRIBE IN DETAIL.
LIST STATES IN WHICH YOU MAY BE LIABLE FOR FILING TAX RETURNSDATE FIRST UNABLE TO WORKDATE OF ACCIDENT OR BEGINNING
OF SICKNESS
DESCRIBE IN YOUR OWN WORDS WHAT IS WRONG WITH YOU (IF ACCIDENT, DESCRIBE
CIRCUMSTANCES AND ADVISE WHETHER IT OCCURRED AT WORK).
DATE YOU PLAN TO RETURN TO WORK
TO BE COMPLETED BY THE CLAIMANT
PLEASE TYPE OR PRINT BE SURE TO ANSWER ALL QUESTIONS - FAILURE TO DO SO MAY DELAY YOUR CLAIM.
USE SEPARATE PIECE OF PAPER TO COMPLETE ANSWERS IF NECESSARY
PLEASE LIST ANY HOSPITALS, CLINICS OR PHYSICIANS THAT TREATED YOU FOR YOUR ILLNESS OR INJURY.
NAME TREATMENT PERIODCOMPLETE ADDRESS
DATE SIGNEDSIGNATURE OF AUTHORIZED REPRESENTATIVE
THIS IS TO CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Page 3 of 5
500385 Rev. 01/2013
IF NOT, PLEASE PROVIDE THE NAME OF YOUR MEDICAL INSURANCE CARRIER
HAVE YOU ELECTED CIGNA HEALTHCARE MEDICAL INSURANCE THROUGH YOUR EMPLOYER?
The issuance of this form is not an admission of the existence of any insurance nor does it recognize the validity of any claim and is without
prejudice to the company’s legal rights.
No Yes
No
Yes
No
Yes
Page 4 of 5
500385 Rev. 01/2013
I authorize any physician, medical professional or other health care provider, hospital or other medical facility; pharmacy; health plan;
other medically related entity; rehabilitation professional; vocational evaluator; employee assistance plan; insurance company,
reinsurer, health maintenance organization, third party administrator, broker or other insurance service provider, or similar entity; the
Medical Information Bureau; the Association of Life Insurance Companies, which operates the Health Claims Index and the Disability
Income Record System; government organization or agency, including the Social Security Administration; financial institution,
accountant or tax preparer; consumer reporting agency; and employer or group policyholder that has information about my health,
prescriptions, financial, earnings or employment history, or other insurance claims and benefits to provide access to or copies of this
information to the Plan and to any individual or entity who provides services to or insurance benefits on behalf of the Plan, including
but not limited to the requesting company(ies) named below ("Company"). To the extent I may be eligible for governmental benefits
similar to or that coordinate with those available to me under the Plan, I also authorize disclosure of information necessary to apply for
or determine my eligibility for such benefits to the relevant government agency and/or vendor providing application assistance.
For any claim for insurance benefits, this authorization is valid for the shorter of 24 months or the duration of my claim. For all other
permitted disclosures, this authorization is valid for one (1) year from the date below. I am entitled to a copy of this authorization and a
photographic or electronic copy of it is as valid as the original.
Disclosure Authorization
AUTHORIZATION
I understand that any information obtained with this authorization will be used for evaluating and administering my coverage,
including any claim for benefits, or otherwise providing services related to or on behalf of the Plan, which may include, but is not
limited to assisting me in returning to work and Plan administration. With respect to governmental benefits similar to or that
coordinate with benefits available to me under the Plan, I understand that the information will be used to help determine my eligibility
for any such benefits and may include assisting me in applying for the benefits. I understand that the information disclosed under this
authorization is subject to redisclosure and may no longer be protected by certain federal regulations governing the privacy of health
information, although it will continue to be protected by other applicable privacy laws and regulations.
I understand that I do not have to give this authorization. If I choose not to give the authorization - or if I later revoke - I understand
that the Plan, insurers, or other providers of services or benefits related to the Plan who rely on this authorization may not be able to
evaluate or administer my request for Plan benefits, coverage or services and that my request for Plan benefits, coverage or services
may be denied as a result. I may revoke this authorization by sending written notice to the Claim Manager handling my claim.
Claimant’s Name:
Information about my health may relate to any disorder of the immune system including but not limited to HIV and AIDS; use of drugs
or alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes.
NOTE: This authorization is designed to comply with HIPAA and relates to information necessary to administer coverage and services
under your employer’s employee health and welfare plan(s) ("the Plan") and similar or coordinating governmental benefits. You are not
required to sign the authorization, but if you do not, the Plan, insurers or other providers of services or coverage under the Plan may
not be able to process your request for Plan benefits, coverage or services.
Company Names: Life Insurance Company of North America, Cigna Life Insurance Company of New York, Cigna Worldwide Insurance
Company, Great-West Life & Annuity Insurance Company, First Great-West Life & Annuity Insurance Company, New England Life
Insurance Company, Alta Health & Life Insurance Company and Connecticut General Life Insurance Company.
(Date of Birth)(Print Name)
(Claimant’s Signature) (Date Signed)
Guardian, or Conservator, please attach a copy of the document granting authority.
(indicate relationship). If Power of Attorney Designee,
I signed on behalf of the claimant as
CLICK TO PRINT
Page 5 of 5
500385 Rev. 01/2013
Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other
person: (1) files an application for insurance or statement of claim containing any materially false information; or,
(2) conceals for the purpose of misleading, information concerning any material fact, may have committed a
fraudulent insurance act.
Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits application or files a claim containing a false or deceptive statement may have violated state
law.
Colorado Residents: 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 settlement or award payable from insurance proceeds shall be reported to the Colorado division
of insurance within the department of regulatory agencies.
Rhode Island Residents: 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.
Texas Residents: 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.
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of 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 Residents: 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 $5000 and the stated
value of the claim for each such violation.
District of Columbia Residents: 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 Residents: 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.
Florida Residents: 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.
Pennsylvania Residents: 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 Residents: 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.
California Residents: 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.
IMPORTANT CLAIM NOTICE
Maryland Residents: 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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

GroupAssociation - Short Term Disability Benefits

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document