Fillable Group Long-Term Disability Claim Form (University of Texas System)

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Group Long-Term Disability Claim Form (University of Texas System)

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Return to Blue Cross and Blue Shield of Texas at:
Attention Claims Department
P.O. Box 7071
Downers Grove, IL 60515
Group Long-Term Disability
Claim Form
Phone Number: (866) 628-2606
Fax: (877) 404-6457
NOTE: All portions of this form package must be completed to avoid undue delay in processing claimant's
request for benefits.
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.
(Not enforceable in Oregon or Virginia.)
NOTICE OF CLAIM — Employer's Instructions
Approximately 6 to 8 weeks before the end of the elimination period:
Complete the Employer's Report of Claim in full;
A. Attach:
• Jobdescription(detailedduties)
• Documentationofearningsifotherthanstraightsalary
• IfWorkers'Comp.claimfiled,includecopyofFirstReportofAccidentandthedecision
B. Return, with all attachments, to Blue Cross and Blue Shield of Texas (BCBSTX) at the
address shown above.
UTSYSTEM GFZ71778
Page 1 of 2
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
R040119 I X6135_uts_BCBSTX
Page 2 of 2
R040119 I X6135_uts_BCBSTX
Employer’s Report Of Claim
To be Completed by Employer
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1. Employee's Name (Last, First, Middle Init.) 2. Benefits ID No. 3. Date of Birth
4. Address City State Zip Code
22. Institution Name 23. Telephone No. 24. Group Policy No.
( )
GFZ71778
25. Address
26. Employer (Taxpayer) I.D. Number (EIN) - 28. Name of person completing this form (please type or print)
OR
27. Public Employer Social Security No. 69
-
29. Signature of Authorized Insurance Representative Title Date
13. How is employee paid? 14. Employee's Basic Monthly Earnings
q Straight Salary q 12 Month Contract
$ ________________________ LTD Benefit ________________________
q Weekly q 9 Month Contract
q Hourly (If salary is based on less than 12 mos. – No. of mos. _________ )
15. Has insured received other disability payments since time last worked?
Salary Continuance: Insured Short Term Disability Other type:
q
Yes Wkly. Amt.
q
Yes Wkly. Amt.
q
Yes Wkly. Amt.
Date benefits cease Date benefits cease Date benefits cease
q
No
q
No
q
No
17. Has Workers' Compensation claim been filed? 18. Workers' Comp.
Weekly Amount:
$
19. Is employee covered by
q Yes 20. Does retirement plan q Yes
employer sponsored contain a disability
retirement plan?
q No provision? q No
21. Is employee or will this
q Yes If “Yes” type:
employee be eligible for
q Monthly Amount $
a disability or retirement
q
Disability
pension?
q
Retirement
Commence Date of Benefits:
Other
(enclose copy of summary plan description)
q
No
NOTE: If any portion of this pension benefit is attributable to the employee's contribution, please provide details including
the percentage of his/her contribution to the total contribution.
5. Insurance Class 6. Employee Date of Hire 7. Date employee became 8.
Date employee was
Insured for LTD actually last present
at work
9. Occupation at time last worked (attach job description) 10. Work schedule at time last worked
No. of days No. of hours
per week per day
11. Reason for stopping:
q Sickness q Granted LOA q Laid Off
q Retired q Dismissed q Other
q Resigned q Vacation
q Yes (Enclose copy of 1st report of accident)
q No
q Pending
q Denied (Enclose copy of denial)
UTSYSTEM GFZ71778
12. Has employee returned to work? q Yes qNo
If Yes:
q Part-time q Full-time
Date______________ Date______________
16. Did claim result
from job activity?
q Yes (Explain)
q No
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
R040119 | Z6291_BCBSTX
Page 1 of 2
The laws of some states require us to furnish you with the following notice:
FOR APPLICATIONS AND CLAIMS:
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 defrauding 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.
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.
Hawaii: For your protection, Hawaii law requires you be
informed that presenting a fraudulent claim for payment
of a loss or benefit is a crime punishable by fines or
imprisonment, or both.
Kentucky: Any person who knowingly and with intent
to defraud any insurance company or other person files
an application for insurance or 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.
Maine & 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.
Maryland: Any person who knowingly or willingly
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 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
knowingly 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.
Oklahoma: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim
for the proceeds of an insurance policy containing 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.
Puerto Rico: Any person who knowingly and with the
intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of
a loss or any other benefit, or presents more than one
claim for the same damage or loss, shall incur a felony
and, upon conviction, shall be sanctioned for each
violation with the penalty of a fine of not less than five
thousand dollars($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for
three (3) years, or both penalties. Should aggravating
circumstances be present, the penalty thus established
may be increased to a maximum of five (5) years,
if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
Rhode Island: 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.
Tennessee: 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
Virginia: 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.
Administrative Offices: 701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
The laws of some states require us to furnish you with the following notice:
FOR CLAIMS ONLY:
Alaska: A person who knowingly and with
intent to injure, defraud, or deceive an
insurance company files a claim containing
false, incomplete, or misleading information
may be prosecuted under state law.
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.
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.
California: For your protection California law
requires the following to appear on this form.
Any person who knowingly presents 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.
Delaware: Any person who knowingly, and
with intent to injure, defraud or deceive any
insurer, files a statement of claim containing
any false, incomplete or misleading information
is guilty of a felony.
Idaho: Any person who knowingly, and with
intent to defraud or deceive any insurance
company, files a statement or claim containing
false, incomplete, or misleading information is
guilty of a felony.
Indiana: A person who knowingly and with
intent to defraud an insurer files a statement
of claim containing any false, incomplete, or
misleading information commits a felony.
Minnesota: A person who files a claim with
intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
New Hampshire: Any person who, with a
purpose to injure, defraud or deceive any
insurance company, files a statement of claim
containing any false, incomplete or misleading
information is subject to prosecution and
punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey: Any person who knowingly files
a statement of claim containing any false or
misleading information is subject to criminal
and civil penalties.
Texas: 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.
FOR APPLICATIONS ONLY:
Massachusetts: 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.
New Jersey: Any person who includes
any false or misleading information on an
application for an insurance policy is subject to
criminal and civil penalties.
R040119 | Z6291_BCBSTX
Page 2 of 2
Administrative Offices: 701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
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Group Long-Term Disability Claim Form (University of Texas System)

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Completed 13 January 2021

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