Fillable SHORT TERM DISABILITY CLAIM FORM (Equitable Life of Canada)

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SHORT TERM DISABILITY CLAIM FORM (Equitable Life of Canada)

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The SHORT TERM DISABILITY CLAIM FORM (Equitable Life of Canada) form is 9 pages long and contains:

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  • 51 check-boxes
  • 263 other fields

Country of origin: CANADA
File type: PDF

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Head Office
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
TF 1.80 0.265.4556 T 519.886.5210
www.equitable.ca
SHORT TERM DISABILITY CLAIM FORM
Plan Member/Employee Section (Please complete in full and provide date and your signature. Incomplete responses or missing information will cause
delays in the assessment and handling of this file.)
If you want Equitable Life to use electronic mail in addition to phone and regular mail for the purpose of communicating with you and to provide
you with information and documentation regarding your disability claim, please provide your e-mail address, and sign and date the consent
below. There is no obligation for you to provide this consent. We can continue to communicate with by phone and regular mail.
I consent to Equitable Life using electronic mail to communicate with me and to provide me with information and documentation regarding my
disability claim.
Signature:
PLEASE NOTE: Equitable Life cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted
and misused.
AUTHORIZATION & ACKNOWLEDGEMENT:
I certify that the information given on this form is true, correct and complete. For the purposes of underwriting, administration, claims processing and adjudication with respect to
the Group Policy and any supplementary forms/documents, I authorize The Equitable Life Insurance Company of Canada (“Equitable”), its employees, representatives and service
providers to use my personal information, and exchange such personal information with reinsurers, insurers, investigative agencies, health care providers and facilities, and any
other person or party whom I authorize. For the above purposes, I authorize any physician, practitioner or other health care provider, hospital, clinic or other medical facility,
pharmacy, insurer, employer (past and present), provincial workers compensation plan, medical or benefit payment plan, service provider, and any other institution, person or party
that has any record or knowledge of my health relevant to this claim, to give to Equitable full particulars of such information, including any prior medical history relevant to this claim
and benefits. I transfer and assign to Equitable, and agree to pay and refund to Equitable those disability and income replacement benefits which I receive or are receivable from
all other sources, in accordance with the provisions of the Group Policy, including without limitation, CPP, Worker’s Compensation, and other insurance policies.
A photocopy or electronic version of this acknowledgement shall be as valid as the original.
Policy number Certificate number Claim number (if known)
Name (first, middle, last) Telephone number Date of birth (dd/mm/yyyy)
Address (number, street and apartment)
City Province Postal code
Date of disability (dd/mm/yyyy) If you have returned to work, give date or expected return date (dd/mm/yyyy)
Yes No If “yes”, date (dd/mm/yyyy) Time a.m. p.m.
Work
Home
Elsewhere
No Yes If “yes”, claim number
Has this claim been approved by the provincial workers
compensation plan?
Yes No
Yes
Cause of disability
Is this claim a result of an accident?
Give full details of the accident
(How and where it happened and resulting injuries)
Location:
If the accident is work related, have you submitted a claim with the provincial workers
compensation plan?
Have you applied or will be applying for or are in receipt of other benefits from any other source such as other insurance, income replacement
benefits from an auto insurer, pension, employment insurance, other government benefits, other income? No
Date of Accident
(dd/mm/yyyy)
Name of Agency or
Auto Insurance Company Claim number
Contact persons name Telephone number
Email address:
Date:
Date
(dd/mm/yyyy) Signature:
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 1 of 9
Accept this as authorization for Equitable Life Insurance Company of Canada to deposit Group claim payments directly into my bank account.
PLEASE ATTACH A VOID CHEQUE OR WE ARE UNABLE TO PROCESS YOUR REQUEST
SHORT TERM DISABILITY CLAIM FORM
Bank’s Name:
Bank’s Address
:
Bank’s Phone No.: ( ) Bank’s Account No.:
area code
Institution Code: Branch Transit No.:
Date Insured’s Signature
Upload the signed and completed form via www.equitablehealth.ca using our secure
Document Submission Tool located under the My Resources tab. You can also fax them to
1.888.505.4373 or mail them to:
Equitable Life of Canada
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
Please note: Equitable Life cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be vulnerable
to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted and misused.
If you would prefer to submit your information by another means, please contact us at 1.80 0.265.4556.
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 2 of 9
1. Employer/Plan Administrator Section (Form should be completed within 7 days of disability. Do not wait until the Plan Member returns to work.
A job description is required and can be provided in the following formats: Equitable Job description form (form 197) or Employer job description/
physical demands analysis. Incomplete responses or missing information will cause delays in the assessment and handling of this file.
Deductions - section must be completed if your plan is Non-taxable
(i.e. employee pays 100% of premiums)
Signature of Plan Administrator
Head Office
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
TF 1.80 0.265.4556 T 519.886.5210
www.equitable.ca
SHORT TERM DISABILITY CLAIM FORM
Plan Member name (first, middle, last) Group Policy number Plan Member’s Certificate/Social Insurance Number
(Required for taxable benefits)
Date of hire (dd/mm/yyyy) Occupation Effective date of insurance
(dd/mm/yyyy)
If terminated/laid off, give date (dd/mm/yyyy)
Date last worked Regular duties Date (dd/mm/yyyy) Partime/modified Date (dd/mm/yyyy)
Date returned to work Regular duties Date (dd/mm/yyyy) Partime/modified Date (dd/mm/yyyy)
For TPA and self-administered groups
please indicate the amount of Short Term Disability coverage: $
Regular Gross Earnings per week
(prior to disability) $
Income Tax $ C.P.P. $ E.I. $
Pension Plan $ Net Earnings $
Employees last paid date
(dd/mm/yyyy):
Is disability due to occupational
accident or sickness?
Yes No
Has disability been reported to the provincial workers compensation plan?
Yes No
Does Plan Member receive any pay or benefits while disabled?
Yes
No If “yes”, give details/comments in Comments section below
Comments: Please include any other information you feel is relevant to this claim.
Employer name Telephone number Fax number
Address
(number, street and suite)
City Province Postal code
Date
(dd/mm/yyyy) Name and Title of Plan Administrator
Plan administrator email
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 3 of 9
2. Employer job description (This section is not required IF you will be attaching a detailed job description including physical and cognitive demands,
environment and work schedule for this employee.)
Describe in detail what the job involves including shift work, weekends, supervisory responsibilities and whether job is dependent upon others or
whether their job depends on this Employee.
SHORT TERM DISABILITY CLAIM FORM
PHYSICAL ACTIVITIES REQUIRED TOTAL HOURS PERFORMED DAILY
Please mark off (x) in the applicable spaces below, those physical activities REQUIRED in this job.
In the no
rmal work day, how long would this Employee be in the following positions if he/she was doing his/her
regular occupation?
If you have a job description or PDA of the Employee’s job, please submit a copy along with the completed form.
List all types of machines, tools, office equipment and other special equipment this Employee uses to do his/her job.
Describe the essential duties of this job.
Describe the work environment with regards to presence of respiratory irritants, noise, humidity, heat, cold, hazards, etc.
Less than 1 1 - 2 3 - 4 5 - 6 7 - 8
LIFTING
Under 10 lbs/(0.5-4.5 kg)
10 - 20 lbs/ (5.0-9.1 kg)
20 - 50 lbs/ (9.5-22.7 kg)
Over 50 lbs/ (22.8kg)
CARRYING
Under 10 lbs/(0.5-4.5 kg)
10 - 20 lbs/ (5.0-9.1 kg)
20 - 50 lbs/ (9.5-22.7 kg)
Over 50 lbs/ (22.8kg)
REACHING
Above shoulder height
At shoulder height
Below shoulder height
CLIMBING
Modified duties or modified work schedule available?
Yes No Comments:
Sitting hours Pushing/Pulling hours Standing hours
Gripping hours Walking hours Pinching hours
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 4 of 9
SHORT TERM DISABILITY CLAIM FORM
2. Employer job description (This section is not required IF you will be attaching a detailed job description including physical and cognitive demands,
environment and work schedule for this employee.)
DRIVING REQUIREMENTS
COGNITIVE DEMANDS
Please check Yes or No in the applicable spaces below
Comprehension
Yes No Information processing Yes No
Visual perception
Yes No Memory Yes No
Attention
Yes No Other Yes No
Is this employee required to drive while at work?
Please describe average time spent driving, type of vehicle and the required licence.
Upload the signed and completed form via www.equitablehealth.ca using our secure
Document Submission Tool located under the Quick Links section. You can also fax them to
1.888.505.4373 or mail them to:
Equitable Life of Canada
Group Life & Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
Please note: Equitable Life cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be vulnerable
to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted and misused.
If you would prefer to submit your information by another means, please contact us at 1.80 0.265.4556.
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 5 of 9
Head Office
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
TF 1.80 0.265.4556 T 519.886.5210
www.equitable.ca
SHORT TERM DISABILITY CLAIM FORM
ATTENDING PHYSICIAN’S STATEMENT
To allow us to make an assessment of your patient’s file, please answer all of the questions in full. Incomplete responses or missing
information will cause delays in the assessment and handling of this file. Any charge for completing this form is the patient’s responsibility.
1. Part 1 to be completed by patient.
2. Part 2 to be completed by physician.
AUTHORIZATION & ACKNOWLEDGEMENT:
I certify that the information given on this form is true, correct and complete. For the purposes of underwriting, administration, claims processing and adjudication with respect to the
Group Policy and any supplementary forms/documents, I authorize The Equitable Life Insurance Company of Canada (“Equitable”), its employees, representatives and service providers
to use my personal information, and exchange such personal information with reinsurers, insurers, investigative agencies, health care providers and facilities, and any other person or
party whom I authorize. For the above purposes, I authorize any physician, practitioner or other health care provider, hospital, clinic or other medical facility, pharmacy, insurer, employer
(past and present), provincial workers compensation plan, medical or benefit payment plan, service provider, and any other institution, person or party that has any record or knowledge
of my health relevant to this claim, to give to Equitable full particulars of such information, including any prior medical history relevant to this claim and benefits. I transfer and assign to
Equitable, and agree to pay and refund to Equitable those disability and income replacement benefits which I receive or are receivable from all other sources, in accordance with the
provisions of the Group Policy, including without limitation, CPP, Worker’s Compensation, and other insurance policies. A photocopy or electronic version of this acknowledgement shall
be as valid as the original.
2. Attending physician’s section (to be completed by the doctor)
1. Plan Member /Employee Information and Consent
(to be completed by the patient)
Plan Member/Employee Name
(Last, First, Middle Initial)
Telephone number
(+ area code) Cell Phone number (+ area code)
Address (number, street and apartment) City Province Postal code
Employer’s Name Policy number Member Certificate #
Height Weight Date of Birth
(dd/mm/yyyy)
Last Date Worked (dd/mm/yyyy) Date Returned to Work or Expected Return to Work Date (dd/mm/yyyy)
Date (dd/mm/yyyy)
Primary Diagnosis:
Secondary and/or Complications:
If childbirth - expected or actual delivery date (dd/mm/yyyy): Vaginal C-Section
Occupational Illness/injury
Yes No
If yes, date of event
(dd/mm/yyyy):
Auto accident Yes No
If yes, date of event
(dd/mm/yyyy):
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 6 of 9
Signature:
Attending physician’s section continued (to be completed by the doctor)
Treatment
(physiotherapy, other):
SHORT TERM DISABILITY CLAIM FORM
Indicate your patients functional capacity below for each question by checking “R” for Restriction (what your patient
should not do) or “L” for Limitation (what your patient is unable to do).
Date of first visit to you pertaining to this condition
(dd/mm/yyyy):
First date of work absence due to condition (dd/mm/yyyy):
Hospitalization Is/was patient hospitalized or had day surgery
Date of admittance
(dd/mm/yyyy) Date of discharge (dd/mm/yyyy) Institution Name
If surgery was performed please provide date and description of surgery Date
(dd/mm/yyyy)
Description:
Medication: Medication: Medication: Medication: Medication: Medication:
Date Started (dd/mm/yyyy)
Initial Dosage
Initial Response
Date of Last Dosage
Change
(dd/mm/yyyy)
Current Dosage
Response
Side Effects
Compliance
Date Medication
Discontinued
(dd/mm/yyyy)
Lifting Under 11lbs (4.98 kg) R L 11-22 lbs (4.98-9.97 kg) R L 22-24 (9.97- 10.88 kg) R L Over 44 (19.95 kg) R
Carrying Under 11lbs (4.98 kg) R L 11-22 lbs (4.98-9.97 kg) R L 22-24 (9.97- 10.88 kg) R L Over 44 (19.95 kg) R
Reaching Above shoulder height R L At shoulder height R L Below shoulder height R L
Sitting hours Overhead Lifting hours
Standing hours Pushing/Pulling hours
Walking hours Gripping hours
Pinching hours Keyboarding hours
L
L
Prognosis Please provide the prognosis for recovery and time line:
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 7 of 9
Attending physician’s section (continued)
Please attach copies of all relevant:
• test results/investigations
• consultation reports
If consultation report is not attached, please indicate if your patient has or will be seen by a specialist for this condition.
SHORT TERM DISABILITY CLAIM FORM
Competency
Has the patient been treated for this same or similar condition in the past?
Yes No
If yes, date:
(dd/mm/yyyy) Treatment Provider:
Please describe the patient’s symptoms including history, severity and frequency:
Frequency of Visits:
Weekly Monthly Other
Name of Specialist Specialty Date of Visit
Please indicate your patients restrictions (what your patient should not do) and limitations (what your patient is unable to do)
Please list any complications and additional conditions impacting your patient’s level of function or the expected recovery period.
Is the patient following the recommended treatment program?
Yes No
Do you believe your patient is competent to cash cheques and use proceeds?
Yes No
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 8 of 9
SHORT TERM DISABILITY CLAIM FORM
7. Notice to physician
The information in this statement will be kept in a life, health, or disability benefits file with the insurer or plan administrator and might be
accessible by the patient or third parties to whom access has been granted or those authorized by law. By providing the information
I consent to such unedited release of any information contained herein.
Attending Physician
(please print)
Certified Specialty
Address
(Street, City, Province, Postal Code)
Telephone number (+ area code)
Fax number (+ area code)
Date signed
(dd/mm/yyyy)
Physician’s Stamp
Signature
Please retain a copy of this form for your records. Completed forms can be Faxed to 1-888-505-4373 OR by mail to (do not use staples):
Equitable Life of Canada
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn Waterloo, Waterloo Ontario N2J 4C7
Please note: Equitable Life cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted
and misused. If you would prefer to submit your information by another means, please contact us at 1.80 0.265.4556.
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
421(2020/06/30) Page 9 of 9
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SHORT TERM DISABILITY CLAIM FORM (Equitable Life of Canada)

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Completed 1 March 2021

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