Fillable Short Term Disability Claim Form Statement Of Employee (Lincoln Financial Benefits)

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Short Term Disability Claim Form Statement Of Employee (Lincoln Financial Benefits)

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Page 1 of 8
GLC11738STD 1/18
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Short Term Disability Claim Form Statement Of Employee
1. Your Information
/ /
Full Name (First)
(M.I.)
(Last Name)
Social Security Number
Date of Birth
Street Address Phone Number
City
State Zip Code Email Address
h Male h Female
2. Your Employer
Employer Name
Group ID Job Title
Policy Number Billing Location
3. Reason for inability to work
Description of Sickness, Injury or Pregnancy
/ /
Date Last Worked
Injury work related?
h Yes h No
Amount $ Date Began Date Will
Terminate
Date
Applied For
Social Security
_________ / / / / / /
Workers’ Comp
_________ / / / / / /
Salary Continuance
_________ / / / / / /
State Disability
_________ / / / / / /
Other Disability
_________ / / / / / /
Sick Pay
_________ / / / / / /
If approved, should Lincoln National Life Insurance Co. withhold Federal Income Taxes from your benets?
(Minimum: $20 per week Short-Term Disability) (Minimum: $88 per Month Long-Term Disability)
4. Other Income Being Received
5.
Who is your treating health care provider?
This is your primary health care professional. Please have
them complete the Attending Physician’s Statement. If you
have additional health care providers, please also complete
the Treating Medical Professional form.
Physician’s Full Name
Phone Number Fax Number
Street Address
City State Zip Code
h Yes h No
If yes, indicate how much?
___________________________
6. Account for Direct Deposit
Bank Name
Routing Number
Account Number
h Checking h Saving
The above statements are true and complete to the best
of my knowledge and belief. I have read and understand
Fraud Warning Statements. I have completed and
attached the Authorization for Release of Information.
/ /
Signature Date
Print Name
Claim Submission Part 1 of 3
(Please see FRAUD NOTICES attached)
The Lincoln National Life Insurance Company
PO Box 2609, Omaha, NE 68103-2609
Toll Free (800) 423-2765 Fax (877) 843-3950
www.LincolnFinancial.com
disabilityclaims@lfg.com
Page 2 of 8
GLC11738STD 1/18
Illness or Injury Supplemental Questionnaire
Instructions: Please answer the questions to the best of your ability and sign and date below.
1. Is someone else responsible for your illness/injury? h Yes h No
2. Are you making a claim against anyone or any insurance company other than Lincoln Financial Group? h Yes h No
If you answered yes to either question above, please answer the following questions:
3. Please describe in detail the cause of your illness or injury: __________________________________________________
________________________________________________________________________________________________
4. Please provide the location and address where the illness or injury occurred: ___________________________________
________________________________________________________________________________________________
5. Please provide the Responsible Party’s information:
1. Name: ________________________________________________________________________________________
2. Address: ______________________________________________________________________________________
3. Telephone Number: ______________________________________________________________________________
4. Insurance Company’s Name: ______________________________________________________________________
5. Claim Number: __________________________________________________________________________________
6. If you have hired an attorney to investigate or prosecute a claim related to your illness or injury, please provide
your attorney’s information:
1. Name: ________________________________________________________________________________________
2. Address: _______________________________________________________________________________________
3. Telephone Number: ______________________________________________________________________________
7. If you have any documents related to any investigation into how your illness or injury occurred, please attach them.
I have answered the above questions to the best of my ability. I understand that fraudulently answering any of these
questions could result in the suspension or termination of my benets. I further understand that I have an obligation to
supplement any of the above responses should any of the above information change in the future.
Print Name: ___________________________________________________________________________________________
Signature: __________________________________________________________ Date: / /
Page 3 of 8
GLC11738STD 1/18
*Please submit a written job description for the employee’s position with this claim form
*Please submit a copy of this employee’s enrollment statement with this claim form
1. This claim is for:
Full Name (First)
(M.I.)
(Last Name)
/ /
Social Security Number Coverage Start Date
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Short Term Disability Claim Form Statement Of Employer
3. Describe Employee’s Role
Job Title
Description of Duties
Amount $ Date Began Date Will
Terminate
Date
Applied For
Retirement Income
________
/ / / / / /
Workers’ Comp
________
/ / / / / /
Salary Continuance
________
/ / / / / /
State Disability
________
/ / / / / /
Other Disability pay
________
/ / / / / /
4. Other Income Being Received
The above statements are true and complete to the best
of my knowledge and belief. I have read and understand
the attached Fraud Warning Statements. I have
completed and attached the Authorization for Release of
Information.
/ /
Signature Date
Print Name
Organization Name
Insurance Class
Group ID
Policy Number
Billing Location Claim Location
2. Employee’s Coverage & Policy
/ /
Date hired
Hours worked in a
standard day
/ /
Date last worked
Hours worked in a
standard week
/ /
Date back to work
full-time
Hours worked on day
last worked
$
Earnings
Frequency (W/M/Y etc.)
Have you considered
job accommodations? h Yes h No
Injury work related?
h Yes h No
5. Employer Contact
Employer Contact Name
Street Address
City State Zip Code
Phone Number Fax Number
Email Address
Claim Submission Part 2 of 3
(Please see FRAUD NOTICES attached)
The Lincoln National Life Insurance Company
PO Box 2609, Omaha, NE 68103-2609
Toll Free (800) 423-2765 Fax (877) 843-3950
www.LincolnFinancial.com
disabilityclaims@lfg.com
Page 4 of 8
GLC11738STD 1/18
1. Patient Information
Full Name (First)
(M.I.)
(Last Name)
Height Weight Blood Pressure
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Short Term Disability Claim Form Physician’s Statement
2. Diagnosis
Primary ICD diagnostic Code (Required) Primary ICD diagnosis Description
Secondary ICD Diagnosis Code
Secondary ICD Diagnosis Description
Social Security Number
Employer Name
Symptoms
Objective Findings (Include copies of any x-rays, laboratory data, EKG’s, MRI’
s, scans and any clinical ndings)
Pregnancy
/ / / / / /
h Vaginal h C-Section
First Treated
Estimated Delivery Date of Delivery
3. Disability Circumstances - Check if applicable
h Illness h Injury h Work Related
If work related or injury, summarize circumstances
/ / / / / /
Symptoms rst Appeared
Reduced Ability to work
Advised to stop work
/ / / / / /
Initial Treatment
Most Recent Treatment
Next Treatment
Dates hospital conned:
/ / / /
Claim Submission Part 3 of 3
The Lincoln National Life Insurance Company is not responsible for charges incurred due to completion of this form. The patient is responsible for any charges associated with form completion.
(Please see FRAUD NOTICES attached)
Date of:
The Lincoln National Life Insurance Company
PO Box 2609, Omaha, NE 68103-2609
Toll Free (800) 423-2765 Fax (877) 843-3950
www.LincolnFinancial.com
disabilityclaims@lfg.com
to
Page 5 of 8
GLC11738STD 1/18
Indicate frequency per day the listed activities below can be used performed using:
N= Never 0% O= Occasionally <33% F= Frequently 34%-66% C= Continuously 67% - 100%
Lifting/Carrying Reaching
1-5 lbs.
_____ Standing ____ Crouching _____ Overhead ______
6-10 lbs. _____ Walking ____ Crawling _____ Desk Level ______
11-25 lbs. _____ Sitting ____ Grasping _____ Below Waist ______
26-50 lbs. _____ Balancing ____ Climbing _____
51-100 lbs. _____ Stooping ____ Pushing _____
100 + lbs. _____ Kneeling ____ Pulling _____
Fingering ____ Bending _____
What job modications would allow the patient to return to work?
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
Short Term Disability Claim Form Physician’s Statement
4. Limitations and Restrictions
Restrictions (what the patient SHOULD NOT do)
Limitations (what the patient CANNOT do)
Describe ongoing treatment frequency
Patient able to return to work
Full-Time on:
/ / / /
If a specic date is unavailable, please provide a
date range you expect a fundamental or marked
change.
Phone Number
Fax Number
/ /
Signature
Date
to
Describe current and recommended treatment plans including any completed or
future surgeries. (Include dates)
6. Prognosis
Describe the patients prognosis for recovery
5. Treatment
7. Physician’s Information
Name
Street Address
City
State Zip Code
Activities of Daily Living
I
f patient cannot complete these activities of Daily living
indicate, when they were rst unable to do so. (M/D/Y)
Continence / /
Dressing / /
Transferring / /
Bathing / /
Toileting / /
Eating / /
Date patient experienced loss of
Cognitive Functioning: / /
Claim Submission Part 3 of 3
(Please see FRAUD NOTICES attached)
The Lincoln National Life Insurance Company is not responsible for charges incurred due to completion of this form. The patient is responsible for any charges associated with form completion.
The Lincoln National Life Insurance Company
PO Box 2609, Omaha, NE 68103-2609
Toll Free (800) 423-2765 Fax (877) 843-3950
www.LincolnFinancial.com
disabilityclaims@lfg.com
Page 6 of 8
GLC11738STD 1/18
1. In connection with a claim for benets, I (the undersigned) authorize any physician, medical professional, pharmacist or
other provider of health care services, hospital, clinic, other medical or medically related facility; insurance or reinsurance company;
government agency; department of labor; acquaintance; group policyholder; employer; or policy or benefit plan
administrator to release information from the records of:
Name of Insured: __________________________________________________________________________________
(Last) (First) (Middle)
Date of Birth: / / Social Security Number: ______________________________________________
2. Information to be released (hereinafter referred to as “My Information”):
• data or records regarding my medical history, treatment, prescriptions, consultations [including medical and psychological
reports, records, charts, notes (excluding psychotherapy notes), x-rays, lms or correspondence, and any medical condition I
may now have or have had];
• any information regarding insurance coverage, claims or benets; and/or
• any information, data or records regarding my activities (including records relating to my Social Security, Workers’ Compensation,
retirement income, nancial information, earnings and employment history).
3. Information to be released to: The Lincoln National Life Insurance Company (“Lincoln”)
PO Box 2609
Omaha, NE 68103-2609
4.
I understand My Information will be used by Lincoln to evaluate and administer my claim for benets. I also authorize
Lincoln to release My Information as follows:
• to its reinsurer, or other persons or organizations performing business or legal services in connection with my claim(s); or
• to a vendor, approved by Lincoln, which specializes in the application for Social Security Disability Benets
• to vendors/consultants providing me with wellness, disability or leave related services as part of an employer sponsored benet plan; or
• for self-insured disability plans only, to my employer; or
• for fully insured plans, I understand the information obtained with this Authorization may be used in discussions
between Lincoln and my employer regarding my functional capacity, and any related restrictions and limitations, in order
to facilitate my return to work; or
• as otherwise may be required by law or as I may further authorize.
5.
I understand My Information may be subject to re-disclosure by the recipient and may no longer be protected by federal or state
law. For Colorado claims, the disclosed information may not be re-disclosed or reused by the recipient under Colorado law.
6.
I understand that I may revoke this Authorization in writing at any time, except to the extent Lincoln has taken action in
reliance on this Authorization. To initiate revocation of this Authorization, direct all correspondence to Lincoln at the above
address. If written revocation is not received, this Authorization will be considered valid for a period of time not to exceed
24 months from the date of my signature below, or the duration of my claim for benets, whichever is shorter.
7. A photocopy of this Authorization is to be considered as valid as the original. I am entitled to receive a copy of this
Authorization.
SIGNATURE ________________________________________________________ DATE / /
Claimant/legal representative (Nearest relative, legal guardian, or appointed representative to sign only if claimant/patient is a
minor, legally incompetent, or deceased.) Power of attorney or guardianship must be attached.
PRINT NAME: ________________________________________________________________________________________
Relationship to Claimant/Patient of personal/legal representative signing for Claimant/Patient __________________________
ADDRESS: ___________________________________________________________________________________________
(Street)
____________________________________________________________________________________________________
(City) (State) (Zip Code)
PHONE NO: __________________________________________________________________________________________
Authorization For Release Of Information
XXX-XX-
(Please see FRAUD NOTICES attached)
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its afliates.
The Lincoln National Life Insurance Company
PO Box 2609, Omaha, NE 68103-2609
Toll Free (800) 423-2765 Fax (877) 843-3950
www.LincolnFinancial.com
disabilityclaims@lfg.com
Page 7 of 8
GLC11738STD 1/18
FRAUD NOTICES. For your protection, certain states require that the following notices appear on this form.
Alabama. 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.
Alaska. A person who knowingly and with intent to injure, defraud, or deceive an insurance company les 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, Louisiana, Rhode Island and West Virginia. Any person who knowingly 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.
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 nes and connement 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, 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.
Delaware. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, les a
statement of claim containing any false, incomplete or misleading information is guilty of a felony.
District of Columbia. 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.
Florida. Any person who knowingly and with intent to injure, defraud, or deceive any insurer les a statement of claim
or 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, les a
statement or claim containing any false, incomplete or misleading information is guilty of a felony.
Indiana. A person who knowingly and with intent to defraud an insurer les 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 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.
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, nes or a denial of insurance benets.
Maryland. Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss
or benet or who knowingly or willfully presents false information in an application for insurance is guilty of
a crime and may be subject to nes and connement in prison.
Minnesota. A person who les a claim with intent to defraud or helps commit a fraud against an insurer is
guilty of a crime.
Page 8 of 8
GLC11738STD 1/18
New Hampshire. 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.
New Jersey. Any person who knowingly les 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
benet or knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to civil nes and criminal penalties.
New York. 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 subject to a civil penalty not to exceed ve thousand dollars and the stated value
of the claim for each such violation.
Ohio. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or les a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma. 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.
Oregon. Any person who knowingly and with intent to defraud any insurance company or other person: (1)
les an application for insurance or statement of claim containing any materially false information; or, (2)
conceals for the purpose of misleading, information concerning any material fact, may have committed a
fraudulent insurance act.
Pennsylvania. 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.
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 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 by 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. Should aggravating circumstances be 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.
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, nes and denial of insurance benets.
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 nes and connement in state prison.
FOR ALL OTHER STATES EXCLUDING CONNECTICUT AND KANSAS. A person may be committing
insurance fraud, if he or she submits an application or claim containing a false or deceptive statement with
intent to defraud (or knowing that he or she is helping to defraud) an insurance company.
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Short Term Disability Claim Form Statement Of Employee (Lincoln Financial Benefits)

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Completed 27 May 2021

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