Fillable SHORT TERM DISABILITY CLAIM FORM The Benets Center (Town of Allenstown)

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SHORT TERM DISABILITY CLAIM FORM The Benets Center (Town of Allenstown)

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For use with policies issued by the following Unum Group [“Unum”] subsidiaries:
Unum Life Insurance Company of America Provident Life and Accident Insurance Company
The Paul Revere Life Insurance Company
OUR COMMITMENT TO YOU
We understand that a disabling illness or injury creates emotional, physical and nancial challenges and we want to do
whatever we can to help you. You have our commitment to provide you with responsive service and to be understanding and
sensitive to your circumstances during the claim process.
Instructions
This form should be completed by you (the employee), your employer and attending physician.
· Employee Statement (pages 4-5): Please complete this section of the claim form and fax it to 1-800-447-2498. If you prefer, it
may be mailed it to the address noted above.
· Please complete the name and date of birth elds at the top of every page for easy identication purposes in case the pages
become separated.
· Authorization to Share Information with Third Parties (page 6): If you wish to give us permission to share the details of your
claim with a third party (such as your spouse, son, daughter, friend, etc.), please sign and date this form and fax it to 1-800-447-
2498. If you prefer, it may be mailed to the address noted above.
· Employee Authorization (last page): Please sign and date this form and provide a copy to your attending physician. Fax the
completed form to 1-800-447-2498 or mail it to the address noted above.
· Employer Statement (pages 7-8): Please ask your employer to complete, sign and date the form and fax it to 1-800-447-2498
or mail it to the address noted above. If you are applying for Individual Short Term Disability benets only, we do not require the
Employer Statement.
· Attending Physician Statement (pages 9-10): Please complete Part I of this statement, then give this section of the claim
form to the physician or treating provider primarily responsible for your care. Ask him/her to complete Part II and fax the
completed form to 1-800-447-2498. If s/he prefers, it may be mailed to the address noted above.
Questions?
If, at any time, you have questions about the claim process or need help to complete this form, please call the above toll-free
number. Our Contact Center is staffed with experienced professionals who can be contacted from 8 a.m. to 8 p.m. Monday
through Friday.
CL-1104 (08/12) 1
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
Instructions (continued) / Claim Fraud Statements
CL-1104 (08/12) 2
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
Fraud Warning
For your protection, the laws of several states, including Alaska, Arizona, Arkansas, Delaware, Idaho,
Indiana, Louisiana, Maine, Maryland, New Mexico, Ohio, Oklahoma, Rhode Island, Tennessee, Texas,
Virginia, Washington, and West Virginia require the following statement to appear on this claim form:
Any person who knowingly and with the intent to injure, defraud or deceive an insurance company presents
a false or fraudulent claim for payment of a loss or benet or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to nes and connement in prison.
Fraud Warning for Alabama Residents
For your protection, Alabama law requires the following to appear on this claim form:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or who knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to restitution nes or connement in prison, or
any combination thereof.
Fraud Warning for California Residents
For your protection, California law requires the following to appear on this claim 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
nes and connement in state prison.
Fraud Warning for Colorado Residents
For your protection, Colorado law requires the following to appear on this claim form:
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, nes, 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.
Fraud Warning for District of Columbia Residents
For your protection, the District of Columbia requires the following to appear on this claim form:
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 nes. In addition, an insurer may deny insurance benets, if false information
materially related to a claim was provided by the applicant.
Fraud Warning for Florida Residents
For your protection, Florida law requires the following to appear on this claim form:
Any person who knowingly and with intent to injure, defraud or deceive any insurer, les a statement of claim or an application
containing false, incomplete or misleading information is guilty of a felony of the third degree.
Fraud Warning for Kentucky Residents
For your protection, Kentucky law requires the following to appear on this claim form:
Any person who knowingly and with intent to defraud any insurance company or other person les 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.
Fraud Warning for Minnesota Residents
For your protection, Minnesota law requires the following to appear on this claim form:
A person who les a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Fraud Warning for New Hampshire Residents
For your protection, New Hampshire law requires the following to appear on this claim form:
Any person who, with a purpose to injure, defraud, or deceive any insurance company, les 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.
Instructions (continued) / Claim Fraud Statements
CL-1104 (08/12) 3
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
Fraud Warning for New Jersey Residents
For your protection, New Jersey law requires the following to appear on this claim form:
Any person who knowingly and with intent to defraud any insurance company or other persons, les 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, subject to criminal prosecution and civil penalties.
Fraud Warning for New York Residents
For your protection, New York law requires the following to appear on this claim form:
Any person who knowingly and with the intent to defraud any insurance company or other person les 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 ve thousand dollars and the
stated value of the claim for each such violation.
Fraud Warning for Pennsylvania Residents
For your protection, Pennsylvania law requires the following to appear on this claim form:
Any person who knowingly and with intent to defraud any insurance company or other person les 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.
Fraud Warning for Puerto Rico Residents
For your protection, Puerto Rico law requires the following to appear on this claim form:
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 benet, 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 ne of not less than ve thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a xed term
of imprisonment for three (3) years, or both penalties. If aggravating circumstances are present, the penalty thus established may
be increased to a maximum of ve (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2)
years.
EMPLOYEE STATEMENT (PLEASE PRINT)
A. Information About You
Last Name Sufx First Name MI
Date of Birth (mm/dd/yy) Social Security Number Gender The state in which you work
Home Address
City State Zip
Telephone Number where we can reach you Preferred e-mail address (for conrmation purposes only)
Employer Name
Language Preference
o
English
o
Spanish
Please check all types of coverage you have with Unum.
o
Group Short Term Disability
o
Individual Short Term Disability
Are you currently self-employed?
o Yes o No Do you work for another employer? oYes o No
If yes, employer name Telephone Number
B. Information About Your Disability
1. For pregnancy, answer the following questions, then go to #4:
What is your expected delivery date? If you have delivered, what was your delivery date? (mm/dd/yy) What type of delivery? o Vaginal o C-Section
Were there any complications causing you to stop If yes, please explain:
work prior to your expected delivery date? o Yes o No
2. For other than pregnancy, is your disability caused by o Illness or o Injury?
What is the name of your medical condition? Date you were rst treated by a physician (mm/dd/yy)
If related to an injury, when, where and how did the injury occur?
3. Is your condition work related? o Yes o No If yes, have you led a Workers’ Compensation claim? o Yes o No
If yes, please explain how the work related injury/illness occurred:
4. Have you been hospitalized? o Yes o No If yes, date hospitalized (mm/dd/yy): through (mm/dd/yy):
5. Last day you were at work (mm/dd/yy) Number of hours worked on date last worked First date you missed work due to this medical condition
(mm/dd/yy)
6. Have you returned to work? o Yes o No If yes, indicate date below.
Part Time (mm/dd/yy): Part-time hours per week: Full Time (mm/dd/yy):
If you have not returned to work, when do you expect to return?
Part Time (mm/dd/yy): Part-time hours per week: Full Time (mm/dd/yy): o Unknown
C. Information About Your Medical Providers
Please provide the following information about your current medical treatment providers (physicians, hospitals, physical therapist, etc.). If you are being treated
by more than one, please share the following information for each provider on a separate sheet of paper and include it with this form.
( ) ( )
____________________________________ ___________________________________ _______________________________
Provider Name Telephone No. Fax No.
____________________________________ ____________________________________
Date of rst visit for this condition (mm/dd/yy) Date of next visit for this condition (mm/dd/yy)
CL-1104 (08/12) 4
o Male
o Female
-
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
EMPLOYEE STATEMENT (Continued)
Employee Name (Last Name, Sufx, First Name, MI) Date of Birth (mm/dd/yy)
D. Information About Income Tax Withholding. The following information will ensure your benet is taxed appropriately according to Federal and State regulations.
TAX INFORMATION
If you do not know if you are covered under a fully-insured or self-insured plan, please contact your employer for assistance.
• ForFully-InsuredPlans – If your claim is approved and your employer tells us your benet is taxable, we are required by law to withhold FICA taxes. Do you
want Unum to also withhold Federal and/or State Income Taxes from your benet checks?
Federal Income Tax: o Yes o No If yes, how much do you want withheld from each check? (whole dollar amount) $_________________
Minimum Withholding: $20/week for Short Term Disability.
State Income Tax: o Yes o No If yes, how much do you want withheld from each check? (whole dollar amount) $_________________
• ForSelf-InsuredPlans – Attach a copy of your completed W-4 for accurate calculation of Federal and State income taxes. Note: If not provided, we are
required by law to withhold 25% of your benet for Federal Income Tax and the maximum withholding amount for State Income Tax.
Fraud Warning: For your protection, Arizona law requires the following to appear directly above your signature:
Any person who knowingly and with the intent to injure, defraud or deceive an insurance company presents a
false or fraudulent claim for payment of a loss or benet or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to nes and connement in prison.
Fraud Warning: For your protection, New York law requires the following to appear directly above your signature:
Any person who knowingly and with the intent to defraud any insurance company or other person les an applica-
tion 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 ve thousand dollars and the stated value of the claim for
each such violation.
E. Signature of Employee/Individual
I have read and understand the fraud notices listed on this form. I also acknowledge that should my claim be overpaid for any rea-
son it is my obligation to repay any such overpayment. The above statements are true and complete to the best of my knowledge
and belief. (Yoursignatureisrequiredforbenetconsideration.)
X
___________________________________________________________________ ________________________________
Signature Date
Reminder: Please sign and date the Authorization (last page of this claim form).
CL-1104 (08/12) 5
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
CL-1104 (08/12) 6
You are not required to sign this Optional Authorization. However, if you would like us to communicate
with a family member, friend or other third party about your claim, we recommend completing the
information below. Please sign and date the form as indicated and mail or fax it to the address or fax
number indicated above.
Optional Authorization to Disclose Information to Third Parties
To assist in the evaluation or administration of my claim(s), I authorize Unum Group, its subsidiaries
and duly authorized representatives (“Unum”) to share personal health and nancial information
relating to my claim with the family members, friends, and/or other third parties listed below:
My Spouse: __________________________________________________________________
(Name) (Telephone Number)
Other Family Member: __________________________________________________________
(Name / Relationship) (Telephone Number)
Other person: _________________________________________________________________
(Name / Relationship) (Telephone Number)
I authorize Unum to leave messages about my claim on my voicemail / answering machine.
o
Yes
o
No
I understand that information about my claim may include information about my health and that such
information about my health may be related to any disorder of the immune system including, but not
limited to, HIV and AIDS; use of drugs and alcohol; and mental and physical history, condition, advice
or treatment, but does not include psychotherapy notes.
I do not wish the following information about my claim to be shared (leave blank if not applicable):
_____________________________________________________________________________
I further understand that the information is subject to redisclosure and might not be protected by certain
federal regulations governing the privacy of health information.
I may revoke this authorization in writing at any time except to the extent Unum or the authorized
recipient of my information has relied on it prior to receiving my notice of revocation. I may revoke this
Authorization by sending written notice to the address above.
This authorization is valid for the shorter of two (2) years or the duration of my claim. I may request a
copy of the Authorization and a copy shall be as valid as the original.
______________________________________________________ ____________________
Employee Signature Date
______________________________________________________ ____________________
Printed Name Social Security Number
I signed on behalf of the employee as ___________________________ (indicate relationship). If
Power of Attorney Designee, Personal Representative, Guardian, or Conservator, please attach a copy
of the document granting authority.
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
EMPLOYER STATEMENT - To be completed by the Employer (PLEASE PRINT)
A. Information About the Employer
Employer Name Employer Telephone Number
Employer Address
City State Zip
B. Information About the Employee
Employee Name (Last Name, Sufx, First Name, MI)
Employee Address
City State Zip
Employee Telephone Number Social Security Number Date of Hire (mm/dd/yy)
Please check all types of coverage this employee has with Unum and provide the information requested.
o Short Term Disability Policy Number Division Number Effective Date
o Long Term Disability Policy Number Division Number Effective Date
o Voluntary Benets Disability Policy Number Effective Date
If this is a Section 125/Cafeteria plan, indicate which option of coverage this employee has chosen.
Previous Plan Year: Current Plan Year:
Date of Open Enrollment (mm/dd/yy): __________________ Option: _______ Date of Open Enrollment (mm/dd/yy): __________________ Option: _______
Is this employee: o Full-time o Part-time o Exempt o Non-exempt o Bargaining o Non-bargaining
Date Last Worked (mm/dd/yy) Number of hours worked on date last worked
Check off regular work days: o Sun o Mon o Tues o Wed o Thurs o Fri o Sat Hours scheduled to work per week:
Did this employee reduce his/her hours prior to his/her last day worked due to this medical condition? o Yes o No
If yes, please provide specic dates and hours worked.
Occupation Title (please attach a copy of the employee’s job description)
Has the employee’s employment been terminated? o Yes o No If yes, termination date (mm/dd/yy):
How was the employee paid? (please check all that apply)
o Hourly o Salary o Overtime o Bonus o Commissions o Other If the policy denes earnings as prior year W-2, please attach a copy.
Salary/Wage prior to date last worked
o Hourly o Weekly o Bi-Weekly o Semi-Monthly Bonuses (per week) $ ____________________________
$ ____________________________ Commissions (per week) $ ____________________________
Employee Pre-Tax Withholdings: Indicate pre-tax withholdings in effect just prior to disability so that earnings will be calculated as dened by the policy.
401(k)/403(b) Pre-tax medical and other insurance Flexible spending account
__________% $ ____________________________/week $ ____________________________/week
Date paid through (mm/dd/yy): For: o Salary Continuation o Vacation Pay o Accrued Sick pay o Other
Other than payments under this policy, will the employee be receiving any other income from you, such as K-1 earnings, bonuses, commissions, salary
continuation, PTO? o Yes o No
CL-1104 (08/12) 7
-
-
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
CL-1104 (08/12) 8
EMPLOYER STATEMENT (Continued)
Employee Name (Last Name, Sufx, First Name, MI) Date of Birth (mm/dd/yy)
Is the claim the result of a work related injury or illness? o Yes o No
If yes, has a Workers’ Compensation claim been led? o Yes o No
CompleteonlyforNewYorkDisabilityBenetsLaworNewJerseyTemporaryDisabilityBenetsSalaryInformation
If this policy provides New York Disability Benets Law or New Jersey Temporary Disability Benets coverage, please provide the earnings for the 8 weeks prior to
disability. (For Disability Benets Law - include the week in which disability began. For Temporary Disability Benets - include the 8 full weeks of income just prior
to date disability began.)
Week Ending Week Ending
Mo. Day Yr. No. Days Amount Mo. Day Yr. No. Days Amount
Worked Worked
1 5
2 6
3 7
4 8
C. Information Needed for Calculation of FICA
What percentage of the Short Term Disability benet is taxable? _____________%
[See IRS Publication 15-A Employer’s Supplemental Tax Guide, Section 6, Sick Pay Reporting and/or IRS Revenue Ruling 2004-55 for more information on
calculating the taxable percent.]
Note: We will assume the benet is 100% taxable if this information is not provided.
D. Information About Your Return-to-Work Program
If the employee is released to return-to-work in restricted duty, are you willing to discuss accommodations? o Yes o No
If yes, who should we contact to discuss a return-to-work plan?
Name Telephone Number
FRAUD NOTICE: Any person who knowingly les a statement of claim containing false or misleading
information is subject to criminal and civil penalties. This includes Employer portions of the claim form.
E.SignatureofBenetAdministrator(PleasePrint)
The above statements are true and complete to the best of my knowledge and belief.
Name of Person Completing Form
Telephone Number Fax Number E-mail Address
Signature Date Signed
X
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
ATTENDING PHYSICIAN STATEMENT (PLEASE PRINT)
PART I: TO BE COMPLETED BY PATIENT
Name of Patient (Last Name, Sufx, First Name, MI) Social Security Number
Date of Birth (mm/dd/yy) Home Telephone Number Employer Telephone Number
Employer Name
PART II: TO BE COMPLETED BY PHYSICIAN OR TREATING PROVIDER
A. Complete this section for pregnancy, then go to section C
Expected Delivery Date (mm/dd/yy): Actual Delivery Date (mm/dd/yy):
Delivery Type: Date of rst visit for this pregnancy Date Hospitalized (mm/dd/yy):
o Vaginal (mm/dd/yy):
o C-Section
Diagnosis: ICD Code: Did you advise your patient to stop working? o Yes o No If yes, on what date (mm/dd/yy)?
Were there any complications causing your patient to stop working prior to her expected delivery date? o Yes o No
If yes, please explain:
B. Complete this section for all conditions except pregnancy, then go to Section C
Date of rst visit for this current condition(s) Date of last ofce visit (mm/dd/yy) Date of next ofce visit (mm/dd/yy) Did you advise your patient to stop working?
(mm/dd/yy): o Yes o No If yes, on what date (mm/dd/yy)?
Has the patient been treated for the same/similar condition in the past? o Yes o No o Unknown
If yes, please provide treatment dates (mm/dd/yy): From Through
Is the patient’s condition work related? o Yes o No o Unknown Patient’s Height: Patient’s Weight
Primary Diagnosis: Primary ICD Code:
Secondary Diagnosis: Secondary ICD Code:
Has the patient been hospitalized? o Yes o No If yes, date hospitalized (mm/dd/yy): through (mm/dd/yy):
Was surgery performed? o Yes o No If yes, what procedure was performed? CPT Code: Date Surgery Performed (mm/dd/yy):
What is your treatment plan? Please include all medications.
CL-1104 (08/12) 9
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
ATTENDING PHYSICIAN STATEMENT (Continued)
Patient Name (Last Name, First Name, MI, Sufx) Date of Birth (mm/dd/yy)
Other Providers: Are you aware of or have you referred your patient to other treating providers? If yes, please provide complete name, contact information and
specialty of any other treating physicians.
Name Specialty Address Phone #
Have you advised the patient to return to work? o Yes o No Expected return to work date (mm/dd/yy): o Full Time o Part Time
Part-time hours per day
CURRENT RESTRICTIONS (activities patient should not do) and CURRENT LIMITATIONS (activities patient cannot do). Please be specic and understand that a
reply of “no work” or “totally incapacitated” will not enable us to evaluate the claim for benets.
What diagnostic or clinical ndings support your patient’s work restrictions and limitations?
FRAUD NOTICE: Any person who knowingly les a statement of claim containing false or misleading
information is subject to criminal and civil penalties. This includes Attending Physician portions of the claim
form.
C. Signature of Attending Physician
The above statements are true and complete to the best of my knowledge and belief.
Physician Name (Last Name, First Name, MI, Sufx) Please Print Degree/Specialty
Address
City State Zip
Telephone Number Fax Number Physician Tax ID Number: Are you related to this patient? o Yes o No
If yes, what is the relationship?
Signature of Physician Date
X
CL-1104 (08/12) 10
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
EMPLOYEE/INDIVIDUAL AUTHORIZATION – FOR EMPLOYEE TO COMPLETE
CL-1104-AUTH (08/12)
Please sign and return this authorization to The Benets Center at the address above. You are entitled to receive
a copy of this authorization. This authorization is designed to comply with the Health Insurance Portability and
Accountability Act (HIPAA) Privacy Rule.
Authorization
I authorize health care professionals, hospitals, clinics, laboratories, pharmacies and all other medical or
medically related providers, facilities or services, rehabilitation professionals, vocational evaluators, health
plans, insurance companies, third party administrators, insurance producers, insurance service providers,
credit bureaus, the MIB Group, Inc., GENEX Services, Inc., The Advocator Group and other Social Security
advocacy vendors, The Association of Life Insurance Companies (which operates the Health Claims Index and
the Disability Income Record System), professional licensing bodies, employers, attorneys, nancial institutions
and/or banks, and governmental entities;
To disclose information, whether from before, during or after the date of this authorization, about my health,
including HIV, AIDS or other disorders of the immune system, use of drugs or alcohol, mental or physical
history, condition, advice or treatment (except this authorization does not authorize release of psychotherapy
notes), prescription drug history, earnings, nancial or credit history, professional licenses, employment history,
insurance claims and benets, and all other claims and benets, including Social Security claims and benets;
To the following persons: Unum Group and its subsidiaries, Unum Life Insurance Company of America,
Provident Life and Accident Insurance Company, The Paul Revere Life Insurance Company, and persons who
evaluate claims for any of those companies (“Unum”), employee benet plans sponsored by my employer and
any person providing services to, or insurance benets on behalf of, such plans, and to anyone who provides
services, including the evaluation of claims, related to benets offered by Unum, my employer, or the Social
Security Administration (“Authorized Recipients”);
For the purposes of evaluating and administering claims, including assistance with return to work. Unum
also may rely on this authorization for one year, or as otherwise permitted by law, to disclose information about
me to the Authorized Recipients so they may conduct health care operations, claims payment, administrative,
and audit functions related to my benet plans.
Information authorized for use or disclosure may include information which may indicate the presence
of a communicable or non-communicable disease.
If I do not sign this authorization or if I alter or revoke it, Unum may not be able to evaluate my claim(s), which
may lead to my claim(s) being denied. I may revoke this authorization at any time by sending written notice
to the address above. I understand that revocation will not apply to any information that is requested prior to
Unum receiving notice of revocation.
The privacy protections established by HIPAA may not apply to information disclosed under this authorization,
but other privacy laws do apply. Information disclosed under this authorization may be redisclosed only as
permitted or required by law, including state fraud reporting laws. For evaluation and administration of claims,
this authorization is valid for two years or the duration of my claim.
____________________________________________________ _________________________
Insured’s Signature Date Signed
____________________________________________________ _________________________
Printed Name Social Security Number
I signed on behalf of the Insured as ________________________________ (Relationship). If Power of Attorney
Designee, Guardian, or Conservator, please attach a copy of the document granting authority.
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
SHORT TERM DISABILITY CLAIM FORM
The Benets Center
P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637
All Other Time Zones Toll-free: 1-800-858-6843
Fax (All Time Zones) Toll-free: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. (Eastern Time).
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SHORT TERM DISABILITY CLAIM FORM The Benets Center (Town of Allenstown)

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Completed 2 August 2020

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