Fillable Short Term Disability Instructions for Filing Claims

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Short Term Disability Instructions for Filing Claims

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CL-INST-STD (4-10)
SM
PO Box 1650
Little Rock, AR 72203-1650
Short Term Disability
Instructions for Filing Claims
Dear Insured:
USAble Life is pleased to provi
de you coverage when you are unable to
work due to a covered disability. We have included these instructions and
the necessary forms to assist you in the event you need to file a claim for
short term disability benefits. Please remember that all forms must be
received within 90 days of the date you stop work.
Employee Statement
1. Complete the Employee Statement in full.
2.
Answer all questions or
state “not applicable”.
3.
Review the attached Fraud Statement
as it applies to your state of
residence, sign and date.
4. Sign and date the Authorization form.
Emplo
yer & Attending Physician Statements
1.
Obtain the statement of your A
ttending Physician who will certify your
disability.
2.
Obtain the statem
ent of your Employer.
Return All Forms to USAble Life:
Email: claims@usablelife.com
Facsimile: (501) 235-8417
Mail: PO Box 1650, Little Rock, AR 72203-1650
For Questions or Assistance Call or Contact USAble Life:
Telephone: (800) 370-5856 Email: claims@usablelife.com
Please return this completed packet to LRSD Human Resources Department to be processed.
CL-LR-STD (9-07) Page 1 of 2 Rev. 4-09
Little Rock School District
Statement of Claim Short Term Disability
Date of Birth
Social Security Number
City, State, Zip
Telephone Numbers
Home Work
PART 2 - EMPLOYEE'S STATEMENT
Street Address
Full Name (Last, First)
Sex
Male Female
INSTRUCTIONS FOR FILING CLAIMS
1. FIRST, HAVE YOUR EMPLOYER COMPLETE EMPLOYER'S STATEMENT.
2. EMPLOYEE SHOULD COMPLETE ALL ITEMS ON THE EMPLOYEE'S STATEMENT. IT MUST BE
SIGNED AND CURRENTLY DATED.
3. HAVE YOUR PHYSICIAN COMPLETE THE PHYSICIAN STATEMENT ON PAGE 2/REVERSE AND
RETURN TO: USABLE LIFE - CLAIMS DEPARTMENT - PO BOX 1650 - LITTLE ROCK, AR 72203-1650
Employer Telephone ( )
Signature Title
Name (Please Print or Type) Date
Little Rock School District 501 447-1100
810 West Markham Little Rock, AR 72201
Address, City, State, ZIP
PART 1 - EMPLOYER'S STATEMENT
Last Day Worked
Group Policy Number
Is Employee eligible for Worker's Compensation?
No Yes
Amount $_______________ per Week
LA 3602
Plan No. Annual Salary Contract Days
No. of Hours Worked
Date Returned to Work
FRAUD WARNING: Except as noted in separate Fraud Notice, it is or may be a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purposes of defrauding the company or other person. Penalties may include
imprisonment, fines, and denial of insurance benefits in accordance with applicable state law.
Date of Hire
Employee's Full Name (Last, First) School/Site of Employee Phone Number of School/Site
Authorization to Obtain Information
I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance
company, health maintenance organization, the Medical Information Bureau (MIB), government entity (federal, state, or local), reinsurer,
or other organization, institution or person that has information, records or knowledge of me or my health, past or present, to furnish
such information to USAble Life (the “Company”), or its agents. I understand that the Company may disclose the information to MIB,
other insurance carriers, reinsurers, claim management/investigation firms, agents, employees and others who have a legitimate
business interest in obtaining the information in connection with underwriting or claim processing. A photostatic copy of this
Authorization shall be as valid as the original. I acknowledge that I have a right to a copy of this authorization upon request.
Date: ________________________ Employee's Signature _________________________________________
Illness Accident
A.M.
Time
Place
P.M.Accident Date
How did the accident happen?
Names and addresses of all doctors consulted for this condition (Use separate sheet if necessary):
Physician
Address, City, State and ZIP
Date of 1st Treatment
Nature of Illness or Injury
Occupation
Claim is for:
FRAUD WARNING: Except as noted in separate Fraud Notice, it is or may be a crime to knowingly provide false, incomplete
or misleading information to an insurance company for the purposes of defrauding the company or other person. Penalties
may include imprisonment, fines, and denial of insurance benefits in accordance with applicable state law.
First Full Day of Disability
Physician's Signature Date
Physician's Name Degree
Address
Date Patient First Consulted You
Date Symptoms First Appeared
If hospitalized:
Inpatient
Outpatient
Hospital Name
Address
City State Zip
Accident
Sickness
Pregnancy
Disability is due to
Did disability arise from patient's employment?
If Pregnancy, estimated delivery date
Yes No
How long was or will patient be disabled/unable to work?
Can return to work on
From
Through
Has Patient Ever Had Same Or Similar Condition?
No
Yes, Date
Describe any circumstances causing disability to be prolonged:
Diagnosis & Concurrent Conditions Include ICD Code
PART 3 - ATTENDING PHYSICIAN'S STATEMENT
(Please Answer All Questions.)
USAble Life
Claims Department
PO Box 1650
Little Rock, AR 72203-1650
Phone: (800) 370-5856
Fax: (501) 235-8417
Return to:
CL-LR-STD (9-07) Page 2 of 2 Rev. 4-09
Admission Date
Discharge Date
Please list all treatment dates during the month in
which disability began.
City, State, ZIP
Date of Birth
Patient's Full Name (Last, First)
FRAUD WARNING: Except as noted in separate Fraud Notice, it is or may be a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purposes of defrauding the company or other person. Penalties may
include imprisonment, fines, and denial of insurance benefits in accordance with applicable state law.
Telephone Fax
CL-FRAUD (4-10)
P.O. Box 1650 ·Little Rock, Arkansas 72203-1650
FRAUD NOTICE
For your protection, the laws of some states may require us to furnish you with the following notice:
Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or a statement of
claim with materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may be guilty of
committing a fraudulent insurance act. Please see below for special notice required by state law.
AZ: 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 loss is subject to criminal and civil penalties.
AR, LA, MD, RI, and WV: 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.
CA: 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.
CO: 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 respect to a settlement or award from insurance proceeds shall be
reported to the Colorado division of insurance within the department of regulatory agencies to the extent required by applicable law.
DE: Any person knowingly and with the intent to injure, defraud or deactivate any insurer, files a statement of claim containing any false, incomplete
or misleading information is guilty of a felony.
DC: WARNING: it is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.
Penalties include imprisonment and /or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim
was provided by the applicant.
FL: 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.
HI: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
punishable by fines or imprisonment, or both.
ID: Any person knowingly and with the intent to defraud or deceive any insurance company, files a statement of claim containing any false,
incomplete, or misleading information is guilty of a felony.
IN: A person knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information
commits a felony.
KY: Any person who knowingly and with the intent to defraud any insurance company or other person files 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.
ME: 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.
MN: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
NH: A person who with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing false, incomplete or
misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
NJ: Any person who knowingly files a statement of claim conta
ining false or misle
ading information is subject to criminal and civil penalties.
NM: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
OH: A person who with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing false or deceptive statement is guilty of insurance fraud.
OK: WARNING: any person who knowingly and with the 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.
OR: A person who knowingly and with the intent to defraud an insurance company, files a claim containing false, incomplete or misleading
information material to such claim, may be guilty of insurance fraud.
PA: 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.
TN, VA and WA: 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.
TX: 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.
Date Signature
Return original with your claim & retain a copy of this authorization and claim form for your records.
H&P-AUTH (4-10)
P.O. Box 1650
Little Rock, AR 72203-1650
Authorization to Disclose, Obtain and Use
Personal Information
In signing below, I represent the statements I may have provided for claim review are
true, complete and correct. I hereby authorize third persons, including, without
limitation: any financial institution, consumer reporting agency, insurance company or
reinsurer, insurance service organization such as the Medical Information Bureau,
benefit plan administrator, health plan, hospital, health care provider, pharmacy,
laboratory, business associate, governmental entity (federal, state, or local), or any
other organization or individual (collectively “Third Parties
”); to disclose the minimum
necessary personal, financial and health information, including physical, psychological,
psychiatric, drug or substance use and communicable disease diagnosis or treatment
information (“Personal Information”) to USAble Life (the “Company”), its representatives
or agents in connection with underwriting, claim evaluation or processing, medical or
disability assessment and management, or treatment, payment, and operations related
activities (the “Permitted Activities”). The Company may possess and further disclose
Personal Information obtained from me, Third Parties, or developed by the Company to
other Third Parties, claim or medical management organizations, investigative firms,
agents, employees, consultants and others who have a legitimate business interest in
obtaining the minimum necessary Personal Information in connection with the Permitted
Activities. If any provision of this authorization is or becomes invalid or unenforceable
pursuant to applicable Federal or State laws, it shall be ineffective only to the extent of
such invalidity or unenforceability, and the remaining provisions of this authorization
shall not be affected.
This authorization is valid for the lesser of: the period that my coverage from the
Company remains in effect or; if this authorization is given in connection with the
Company’s consideration of a claim for benefits, for the duration of the Company’s
consideration of that claim. I have the right to revoke this authorization, in writing, at
any time or to refuse to sign this authorization. I acknowledge that if I do so, that
revocation may adversely affect the completion of the Permitted Activities, including the
denial of a claim for benefits. Any written revocation of this authorization shall become
effective upon receipt by the Company, but shall not apply retroactively as to Personal
Information that has been previously disclosed, obtained or used in accordance with this
authorization. A photocopy of this form is as valid as the original. A copy of this
authorization will be provided to me or my authorized representative upon request.
I have executed this authorization intending that it will be effective on and afte
r
(
Date
)
Signature
Printed Name
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Short Term Disability Instructions for Filing Claims

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Completed 24 December 2021

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