Fillable Group Long Term Disability (Cigna Medicare Providers)

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Group Long Term Disability (Cigna Medicare Providers)

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The Group Long Term Disability (Cigna Medicare Providers) form is 3 pages long and contains:

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  • 15 check-boxes
  • 195 other fields

Country of origin: US
File type: PDF

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Group Long Term Disability
PLEASE DESCRIBE IN YOUR OWN WORDS WHAT IS WRONG WITH YOU (IF ACCIDENT, OR WORK-RELATED, DESCRIBE CIRCUMSTANCES)
Are you married, or do you have a domestic partner or civil union partner?
Do you have any children under age 25?
Do you have any handicapped children (regardless of age)?
If you answered "Yes" to any of the above questions, please list below.
500469 Rev. 03/2016
SOCIAL SECURITY NO.NAME ( Last, First, M.I.)
MAILING ADDRESS (Address where you may be reached during the next six months)
DATE OF ACCIDENT OR BEGINNING OF SICKNESS FIRST DATE YOU WERE UNABLE TO WORK DATE YOU PLAN TO RETURN TO WORK
NAMES OF HOSPITALS COMPLETE ADDRESS
NAMES OF ALL ATTENDING PHYSICIANS CONSULTED FOR THE DISABILITY
LIST STATES IN WHICH YOU MAY BE LIABLE FOR FILING TAX RETURNS
COMPLETE ADDRESS AND PHONE NUMBER
DATE FIRST CONSULTED
DATE ENTERED-DATE DISCHARGED
If not, please provide the name of your medical insurance carrier
5.
If yes, please attach a copy of your Social Security notice for you and your dependents or a copy of your Social Security denial. If you have not applied, please do so as
soon as possible. If you have not received a determination, please attach a copy of your receipt for application.
1.
Date Paid Thru
Salary Continuance
State Disability Benefits
Group Disability Benefits
Workers’ Compensation
Pension Benefits
No-Fault Auto Disability insurance
Any other Disability Income (please identify)
Veterans’ Benefits
Date Began
$ Amount/Frequency
Are you receiving or eligible to receive:
I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT.
SIGNATURE OF EMPLOYEE:
DATE:
TO BE COMPLETED BY THE EMPLOYEE
SEX
(Zip Code)
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
DATE OF BIRTH
NAME RELATIONSHIP GENDER DATE OF BIRTH SOCIAL SECURITY NO.
PHONE NUMBER (Includes Area Code)
Have you applied for Social Security Benefits?
Are you covered under a life insurance policy provided by a Cigna underwriting company?
Page 1 of 4
2.
3.
4.
Cigna
P.O. Box 709015
Dallas, TX 75370-9015
Facsimile (800) 642-8553
MAIL OR FAX TO:
If yes, does this life insurance policy contain a waiver of premium provision?
Have you elected Cigna HealthCare medical insurance through your Employer?
Life Insurance Company of North America
Connecticut General Life Insurance Company
Cigna Life Insurance Company of New York
Great-West Healthcare Administered by Cigna
FM
No
Yes
No
Yes
No
Yes
F
M
F
M
F
M
F
M
F
M
No Yes
No Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
NEW YORK FRAUD WARNING: 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.
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, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas or Virginia.
CLEAR FORM
PLEASE COMPLETE IN FULL
TO BE COMPLETED BY THE EMPLOYER
NAME OF EMPLOYEE (Last, First, M.I.) SOCIAL SECURITY NO. ACCOUNT NUMBER
DATE HIRED
EFFECTIVE DATE OF EMPLOYEE’S LTD
COVERAGE WITH CIGNA CO.
WAS EMPLOYEE’S LTD INSURANCE ISSUED ON THE BASIS OF A STATEMENT OF PHYSICAL
CONDITION?
IF YES, ATTACH COPY
BASIC EARNINGS
Wk. Mo.
DATE OF LAST CHANGE IN EARNINGS
LAST DATE(S) WORKED
# Hrs.
Supervisory
DATE(S) RETURNED TO WORK
PLEASE CHECK THE APPROPRIATE BLOCKS:
Exempt
Management Union Local # Salaried Full Time Part Time
Non-Supervisory
Non-Exempt
Non-Management Non-Union Hourly
Hrs/wk:
HAS EMPLOYEE BEEN TERMINATED?
NAME AND ADDRESS OF WC CARRIER AND WC CLAIM NUMBER
IS EMPLOYEE ELIGIBLE FOR GROUP
PENSION
$
%
IF YES, MONTHLY AMOUNT EMPLOYEE % CONTRIBUTION
To Pension
$
IF YES, DATE REASON
PERCENTAGE OF EMPLOYEE CONTRIBUTION TOWARD
DISABILITY PREMIUM(see Internal Revenue Code Section
105(a) and Regulations thereunder)
PREMIUM PAID THRU DATE
%
WAS SALARY CONTINUED BEYOND LAST DAY WORKED?
HAS EMPLOYEE RECEIVED SHORT TERM BENEFITS?
HAS EMPLOYEE RECEIVED STATE DISABILITY BENEFITS?
HAS EMPLOYEE FILED A WORKERS’ COMPENSATION CLAIM?
DISABILITY
PENSION
IF YES, WEEKLY AMOUNT PAID THRU
EFFECTIVE
IF YES, WEEKLY AMOUNT
FROM
IF YES, WEEKLY AMOUNT
IS THIS A
FROM
$
EARLY
RETIREMENT
IF YES, WEEKLY AMOUNT
$
$
THRU
approved or pending?
NORMAL
RETIREMENT
If yes,
THRU
FROM THRU
LIST ANY OTHER SOURCE OF INCOME TO WHICH THE EMPLOYEE IS ENTITLED AS A RESULT OF THIS DISABILITY
OCCUPATION
(ATTACH JOB DESCRIPTION IF AVAILABLE: IF NOT, DESCRIBE JOB DUTIES BELOW)
Was employee’s job primarily sedentary or did it involve considerable physical activity?
AS CLOSELY AS POSSIBLE, PLEASE ESTIMATE THE PERCENT OF TIME SPENT (TOTAL PERCENTAGE MUST EQUAL 100%):
Sitting
Standing
Walking
Climbing
Stooping
Bending
Pushing
Lifting
Carrying*
*If job duties require lifting or carrying, indicate average and maximum weights handled.
REMARKS
EMPLOYER DIVISION
ADDRESS TELEPHONE NUMBER
AUTHORIZED REPRESENTATIVE DATE
PRINT: SIGNATURE:
HAVE ALL PAGES OF THE FORM BEEN COMPLETED IN FULL?
ATTACH THE ATTENDING PHYSICIAN’S STATEMENT OF DISABILITY AND ANY OTHER DOCUMENTATION.
If yes, does this life insurance policy contain a waiver of premium provision?
Is this individual covered under a life insurance policy provided by a Cigna underwriting company?
Page 2 of 4
EMPLOYEE’S CONTRIBUTIONS WERE MADE ON:
500469 Rev. 03/2016
No Yes
No Yes
No
Yes
No Yes
No
Yes
No
Yes
No Yes
No Yes
No
Yes
Post-tax BasisPre-tax or
Page 3 of 4500469 Rev. 03/2016
Disclosure Authorization
AUTHORIZATION
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:
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
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 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; any of your social security
disability advocates or representatives; 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.
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.
If my employer, union, and/or group association sponsors any other plans, whether or not underwritten or administered by a Cigna
company, the information and/or records obtained may also be shared with the underwriting company (insurer) or administrators of
those other plans, including their internal or external health management, disease management, wellness, employee/member
assistance program or other similar programs, for the purpose of administering any service, benefit or feature described in those plans.
CLICK TO PRINT
Page 4 of 4
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.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information
is subject to criminal and civil penalties.
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.
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.
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.
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.
500469 Rev. 03/2016
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Group Long Term Disability (Cigna Medicare Providers)

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Completed 3 March 2021

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