Fillable Mutual of Omaha Short-Term Disability Claim Form

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Mutual of Omaha Short-Term Disability Claim Form

On average this form takes 75 minutes to complete

The Mutual of Omaha Short-Term Disability Claim Form form is 7 pages long and contains:

  • 7 signatures
  • 63 check-boxes
  • 241 other fields

Country of origin: US
File type: PDF

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Important Tips for Paper Copy Submission
n
Prior to submission, make sure you have provided
all required information and answered all questions
completely and accurately. If information is missing or
cannot be read, the processing of your form will be delayed.
n
The following guidelines provide valuable information to
help you successfully complete the form.
n
Please make a copy of the completed form for your records
before submitting it to Mutual of Omaha/United of Omaha.
Section 1: Employee Statement
This section is to be completed by the Employee. Dates
should include the month, date and year. In order to be
considered complete, the form must be signed by you.
n
Group ID Number for your Employer will consist of eight
characters, beginning with “G000” and followed by four
additional letters or numbers specific to your Employer.
n
Job Title is the title of your position held with the Employer.
n
The Hours Worked per Week is the number of hours you
worked per week for the Employer.
n
Height should be provided in feet and inches.
n
Weight should be provided in pounds.
n
Dominant Hand indicates whether you are primarily right-
or left-handed.
n
Date of Disability is the first day you were absent from work
because of the disabling condition.
n
Date First Treated is the date you first sought medical care
because of the disabling condition.
n
Other Income means money you are currently receiving
or have applied to receive from any source in addition to
your claim for disability benefits with Mutual of Omaha/
United of Omaha.
Authorization to Disclose Personal Information &
Authorization to Disclose Health Information
to my Employer
Both authorizations are to be completed by the Employee.
Dates should include the month, date and year. In order to be
considered complete, the form must be signed by you or your
legal representative.
n
By signing the authorization, you are applying for short-
term disability benefits with Mutual of Omaha/United of
Omaha and are agreeing to allow disclosure of personal
information to the necessary parties for the purpose of
claim processing.
n
If the name associated with any of your medical records
differs from the name provided on the form, provide any
alternate names. This might occur in the event of a name
change due to marriage or adoption.
Guidelines for Section 2: Employer’s Statement
This section is to be completed by the Employer. Dates should
include the month, date and year. In order to be considered
complete, the form must be signed by the Employer.
n
Group ID Number consists of eight characters, beginning
with “G000” and followed by four additional letters or
numbers.
n
Date Covered Under This Plan indicates the date in which
the Employee’s coverage became effective.
n
If the Employee is eligible for salary continuation/sick
leave, this does not include Mutual of Omaha/United of
Omaha short-term disability benefits, paid time off or
vacation compensation.
Guidelines for Section 3: Attending Physician’s
Statement
This section is to be completed by the Attending Physician.
Dates should include the month, date and year. In order to
be considered complete, the form must be signed by the
Attending Physician.
Required Fraud Warnings
Before completing the claim form, please read the Required
Fraud Warnings listed on the following page.
A Guide for Successfully Completing the
Group Short-Term Disability Claim Form
Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the
information you provide on this form to effectively determine if you qualify for group short-term disability benefits.
This guide provides information and instruction to help you successfully complete and submit the claim form. Please
consult your employer/benefits administrator if you need assistance in providing information for the form.
MUG6110A_0415 STD Claim Form Guide_1009
Short-Term Disability Claim Form
Mutual of Omaha Insurance Company
United of Omaha Life Insurance Company
Group Insurance Claims Management
3300 Mutual of Omaha Plaza
Omaha, NE 68175-0001
Phone 800-877-5176 Fax 402-997-1865 Email newdisabilityclaim@mutualofomaha.com
Section 1 – Employee Statement (Answer all questions to avoid delay)
Current Employer’s Name Group ID Number Job Title Hours Worked
per Week
Name
Address City State ZIP
(Area Code) Home Telephone Number (Area Code) Cellular Telephone Number Social Security Number
Email Address
Date of Birth Height Weight Dominant Hand: n Male n Single n Widowed
n Right n Left n Female n Married n Divorced
Date of Disability (1st Day Absent) Date First Treated Estimated Return to Work Date
Nature of illness and when symptoms first appeared, or describe how and where accident occurred.
Was the disability work related? n Yes n No Have you filed a Workers’ Compensation claim? n Yes n No
Was disability related to a motor vehicle accident or is another third party liable? n Yes n No
Physician’s Name
Other income you have filed for, are receiving, or are eligible for:
Amount Date Claim Filed Date Benefits Began
Workers’ Compensation $ ________________ ___________________________ ___________________________
State Disability $ ________________ ___________________________ ___________________________
Other $ ________________ ___________________________ ___________________________
Overpayment Notice: Should you become overpaid at anytime during the duration of this claim we, Mutual of Omaha
Insurance Company (Mutual) or United of Omaha Life Insurance Company (United), will request reimbursement of the
overpaid amount. This amount is equal to the net benefit you received and any Federal Income Tax paid on your behalf for
any time prior to current tax year. Your signature on the claim form authorizes Mutual or United to recover any overpaid
Medicare and/or Social Security Tax that was paid on your behalf and certifies you will not attempt to recover a refund or
credit of the Medicare and/or Social Security Tax with any Form W-2C that is furnished to you based on recoveries received.
Important Notice: If you have group life insurance through your employer, please contact your benefits administrator as soon
as possible to determine what options are available to you to continue your life insurance. Some options require action within
31 days of the date you stop working/insurance ends for life insurance to continue.
If your coverage is written in California, North Carolina or Michigan and includes Survivor Benefits, please check your policy to
determine if you can elect a survivor benefit beneficiary. If so, you may obtain a Beneficiary Designation form on the Internet or
from your employer.
Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing false, incomplete, or misleading information is guilty of a felony of the third degree.
Employee’s Signature: ____________________________________________________ Date: _____________________________
MUG6110A_0415 Page 1 of 6 Form continued on Page 2
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Authorization to Disclose Personal Information
1. I authorize any physician, medical or dental practitioner, hospital, clinic, pharmacy benefit manager, other medical care
facility, health maintenance organization, insurer, employer, consumer reporting agency and any other provider of medical
or dental services to release records containing the personal information of:
Claimant/Patient Name: _____________________________________________________________________________
(Last) (First) (Middle)
Date of Birth: _____/_____/__________
2. Personal information includes medical history, mental and physical condition, prescription drug records, alcohol or drug
use, financial and occupational information.
3. You may release information to:
Group Disability Management Services
Mutual of Omaha Insurance Company/United of Omaha Life Insurance Company
3300 Mutual of Omaha Plaza
Omaha, NE 68175-0001
Or
Fax 402-997-1865
Or
Email newdisabilityclaim@mutualofomaha.com
4. I understand that the personal information that is disclosed will be used by Mutual of Omaha Insurance Company and
United of Omaha Life Insurance Company to evaluate my claim for disability benefit plan reimbursement and that if I refuse
to sign this authorization my claim for benefits may not be paid.
5. I understand that if the person or entity to whom information is disclosed is not a health care provider or health plan
subject to federal privacy regulations, the personal information may be redisclosed without the protection of the federal
privacy regulations.
6. This authorization will expire 24 contiguous months after the date signed.
7. I understand that I may revoke this authorization at any time by providing a written request to Mutual of Omaha Insurance
Company and United of Omaha Life Insurance Company at the address above. If I revoke this authorization, it will not affect
any use or disclosure of personal information that occurred prior to the receipt of my revocation.
8. I understand that I am entitled to receive a copy of this authorization and that a copy is as valid as the original.
RETAIN A SIGNED COPY FOR YOUR RECORDS
Name(s) used for records (if different than the name below): ________________________________________________________
___________________________________________________________________________________________________________
________________________________________________________________________ ________________________________
Signature of Claimant Date
If Applicable: I am the legal representative of the claimant and I am authorized to grant permission on behalf of the claimant.
Printed Name of Legal Representative:___________________________________________________
Signature of Legal Representative: ______________________________________________________
Type of Legal Representative: __________________________________________________________
THIS AUTHORIZATION COMPLIES WITH HIPAA AND OTHER FEDERAL AND STATE LAWS
MUG2854_0815
MUG6110A_0415 Page 2 of 6 Form continued on Page 3
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Authorization to Disclose Health Information to My Employer
I authorize Mutual of Omaha Insurance Company and United of Omaha Life Insurance Company to disclose health information
about me to my employer, and to my employer’s broker. I understand that this information will be used by my employer, and
its broker, to monitor and manage the disability benefits program provided under my Group disability policy. I also understand
that my employer and its broker will use the information solely for the purposes of auditing disability benefits paid, providing
claims assistance, determining waiver or discontinuance of premium deductions, and coordinating with other subsidized salary
continuance plans my employer may offer.
The health information which may be disclosed pursuant to this authorization includes such items as medical history, mental
and physical condition, prescription drug records and alcohol or drug use.
I understand that I may refuse to sign this authorization. I realize that if I refuse to sign, my claim for benefits may not be paid.
This authorization will remain in effect for 24 contiguous months from the date I sign it. I understand that I may revoke this
authorization at any time. If I would like to revoke this authorization, I should send my revocation request to:
ATTN: Group Disability Management Services
Mutual of Omaha Insurance Company/United of Omaha Life Insurance Company
3300 Mutual of Omaha Plaza
Omaha, NE 68175-0001
Or
Fax 402-997-1865
Or
Email newdisabilityclaim@mutualofomaha.com
I also understand that any revocation of this authorization will not affect any use or disclosure of health information that
occurred prior to receipt of my revocation.
I understand that I am entitled to receive a copy of this authorization. A copy of this authorization is as effective as
the original.
___________________________________________________________________________________________________________
(Printed Name and Address)
________________________________________________________________________ ________________________________
Signature Date
or
If Applicable: I am the legal representative of the person whose financial and health information is to be disclosed, but I am
authorized to grant permission on behalf of that person.
Printed Name of Legal Representative: __________________________________________________________________________
Signature of Legal Representative: ______________________________________________________________________________
Type of Legal Representative: __________________________________________________________________________________
Date: ___________________________
RETAIN A SIGNED COPY FOR YOUR RECORDS
MUG6893_0815
MUG6110A_0415 Page 3 of 6 Form continued on Page 4
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Section 2 – Employer’s Statement (Answer all questions to avoid delay)
Company Name Group ID Number Master Policy Number
Class No. or Description Division/Location No. or Description
Address City State ZIP
Email Address
Employee’s Name Employee’s Phone Number
Employee Address Employee City Employee State Employee ZIP
Weekly earnings as defined by the Plan: ________________
Number of weekly hours worked: _________
(Please note: Benefits will be calculated based on premium received.)
Salary Effective Date: _____________________________________________
Was disability caused by employment? n Yes n No Has workers’ compensation claim been filed? n Yes n No
Does the Employee contribute toward the premium? n Yes n No
If yes, what percent is paid by the Employee? ______% Is it Pre-tax or Post-tax? _________________
Employee’s payroll classification n Exempt n Non-Exempt n Salaried n Hourly n Union n Non-Union n Other
How was the Employee paid? __________________________
Is the Employee continuing to receive compensation or pay since their last day of work? n Yes n No
If yes, what is the weekly amount of the type of compensation being received and the period payable?
Amount __________ Salary Continuation Start __________ End __________ Amount __________ Vacation Start __________ End __________
Amount __________ Sick Leave Start __________ End __________ Amount __________ PTO Start __________ End __________
Amount __________ Severance Start __________ End __________ Amount __________ Other Start __________ End __________
If other is marked, please describe ________________________________________________________________________________________________________
Date of Hire: Date Covered Under This Plan:
Does Mutual of Omaha cover the Employee for group long-term disability? n Yes n No
Does United of Omaha Life Insurance Company cover the Employee for group life? n Yes n No If so, please complete the following.
Name of Employee’s beneficiary according to your records:______________________________________ Relationship to Employee:_______________________
Important Notice: For Employees age 60 or over, refer to the policy provisions regarding group life continuation and conversion rights.
Does Mutual of Omaha cover the employee under an additional short-term disability policy? n Yes ___________________ (policy number) n No
Please contact Employee’s direct supervisor and then circle the strength demand below which best describes the Employee’s job:
S – Sedentary 10 lbs. Maximum lifting, occasional lift/carry of small articles. Some occasional walking or standing may be required.
L – Light 20 lbs. Maximum lifting with frequent lift/carry up to 10 lbs. A job is light if less lifting is involved but
significant walking/standing is done or if done mostly sitting but requires push/pull on arm or leg controls.
M – Medium 50 lbs. Maximum lifting with frequent lift/carry up to 25 lbs.
H – Heavy 100 lbs. Maximum lifting with frequent lift/carry up to 50 lbs.
V – Very Heavy Over 100 lbs. Lifting with frequent lift/carry over 50 lbs.
Employee’s Job Title Last Day at Work
What was the Employee’s employment status on the first day absent?
Description of major job duties – Please attach job description Has the Employee returned to work? n Yes n No
a) If yes, when?
b) If not, what is the estimated return to work date?
Can the Employee’s job be modified? n Yes n No
Signature of Person Completing Claim Form Title of Person Completing Claim Form
Date Signed (Area Code) Phone Number (Area Code) Fax Number Email Address
Please notify us if the Employee returns to work after the submission of this form.
Circle
One
{
MUG6110A_0415 Page 4 of 6 Form continued on Page 5
Page 4 of 6
FAX (402) 997-1865 Email newdisabilityclaim@mutualofomaha.com Form must be completed in full at no expense to Mutual of Omaha
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signature
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Section 3 – Attending Physician’s Statement (Answer all questions to avoid delay)
Employer Name Group ID Number
Name of Patient (Last, First, MI) – Please Print Date of Birth Employee’s Phone Number
Employee Address Employee City Employee State Employee ZIP
Diagnoses ICD-9 Code(s)
Symptoms Date symptom first appeared
Initial date of treatment: Last date of treatment: Next date of treatment/office visit:
Is disability due to: n Accident/Injury n Sickness Is the disability work related? n Yes n No
If applicable, list the surgical procedure(s) – Describe fully and provide dates if any.
If disability is due to Pregnancy, please provide the information below:
Date of Last Monthly Period Expected Date of Delivery Expected Type of Delivery
n Vaginal n Cesarean Section
Actual Date of Delivery Actual Type of Delivery
n Vaginal n Cesarean Section
If any of the following questions are answered “Yes,” then please provide the information to the right of that question.
Was the patient treated in an Date treated Name of Hospital Name of Physician
Emergency Room? n Yes n No
Did another physician treat or will be Date treated Physician’s Name and Address
treating the patient? n Yes n No
Was the patient hospital confined? Date Confined In Hospital: Name of Hospital
n Yes n No From______________ To________________
Did patient have outpatient surgery in a hospital Date of Surgery Name of Facility
or ambulatory surgical center? n Yes n No
Functional Limitations – Abilities
Please notify us if the Employee returns to work after the submission of this form.
Indicate frequency per day the listed activity can be performed.
(n = never, o = occasional, f = frequent, c = constant)
Lifting Carrying
__________1-5 lbs. __________1-5 lbs.
__________6-10 lbs. __________6-10 lbs.
__________11-25 lbs. __________11-25 lbs.
__________26-50 lbs. __________26-50 lbs.
__________51-100 lbs. __________51-100 lbs.
__________Over 100 lbs. __________Over 100 lbs.
Indicate longest single time duration each activity can be performed.
_____ Sitting _____ Kneeling _____ R: Finger Dexterity
_____ Total time on feet _____ L: Finger Dexterity
_____ Standing _____ Inside _____ R: Below Shoulder
_____ Walking _____ L: Below Shoulder
_____ Bending _____ Outside _____ R: Above Shoulders
_____ Squatting _____ Working with _____ L: Above Shoulders
Others
_____ Stooping _____ Other (explain)__________________________________
Reaching
}
MUG6110A_0415 Page 5 of 6 Form continued on Page 6
Page 5 of 6
FAX (402) 997-1865 Email newdisabilityclaim@mutualofomaha.com Form must be completed in full at no expense to Mutual of Omaha
Mental Limitations – Abilities
Please check off the appropriate response of the person’s ability to adapt to these specific job situations at this time.
Somewhat Markedly Unable to
Unlimited Limited Limited Perform
Follow work rules.........................................
Perform repetitive, or short cycle work .......................
Perform at a constant pace.................................
Maintain attention and concentration........................
Perform a variety of duties .................................
Understand, remember and carry out complex job instructions ...
Attain set limits and standards .............................
Relate to co-workers ......................................
Interact with supervisors ..................................
Interact with the public/customers ..........................
Use judgment and make decisions ..........................
Direct, control or plan activities of others .....................
Influence people in their opinions, attitudes and judgments .....
Expressing personal feelings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Work alone or apart in physical isolation from others . . . . . . . . . . .
What functions of the person’s own/usual occupation is the person unable to perform? (Please provide rationale here, if not already provided.)
What functional restrictions have been placed on this person?
The patient has been continuously disabled (unable to work) from ____________________________ to ____________________________
Is the patient able to work with job modifications? n Yes n No
The patient should be able to work n Full-time n Part-time on ______________________ or a specific date is unavailable, in
n 1 month n 1-3 months n 3-6 months n Other (please specify)
Remarks and/or treatment plan
Name of the Attending Physician – Please Print Specialty/Degree(s) Tax Identification Number
Address (No., Street, City, State, ZIP) (Area Code) Telephone Number (Area Code) Fax Number
If necessary, whom can we contact at the attending physician’s office for additional information?
Name: (Area Code) Telephone Number:
Signature of Attending Physician Date
Please notify us if the Employee returns to work after the submission of this form.
MUG6110A_0415 Page 6 of 6
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FAX (402) 997-1865 Email newdisabilityclaim@mutualofomaha.com Form must be completed in full at no expense to Mutual of Omaha
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The following fraud language is attached to, and made part of this claim form. Please read and do not remove
these pages from this claim form.
** 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.
** 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 and 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.
** 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 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.
** 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.
** District of Columbia: WARNING: It is a crime to provide false or misleading information to an 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.
** Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a
statement containing any 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.
** Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance 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.
** 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.
Group Claim Fraud Statements
United of Omaha Life Insurance Company
A Mutual of Omaha Company
MUG6110A_0415
** 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.
** 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 of 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.
** 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
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 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.
** 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, Virginia, and 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.
** 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.
** If you live in a state other than mentioned above, the following statement applies to you: Any person
who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a
statement of claim containing any materially false, incomplete, or misleading information or conceals any
fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be
subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefits if
false information is related to a claim by the claimant.
MUG6110A_0415
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Mutual of Omaha Short-Term Disability Claim Form

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