Fillable Sun Life Assurance Company of Canada (Cape Fear Community College)

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Sun Life Assurance Company of Canada (Cape Fear Community College)

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XGR/1640 LTD Claim Packet - Employer Page 1 of 7
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long Term Disability Claim Packet - Employer
Instructions for the Plan Administrator
Please call our Customer
Service Center at 1
-800-
247
-6875 from 8 a.m. to
8 p.m. Eastern Time
to
report any scheduled or
act
ual return-to-work dates
as soon as possible.
Please make sure that the employee initiates the Long Term Disability claim filing process as soon
as it first appears that his or her disability will extend beyond the required elimination period. Please refer
to your group insurance policy to determine the length of the elimination period.
Please be sure to submit the Employer’s Statement directly to Sun Life Financial
.
The Employer must:
Attach a copy of the LTD enrollment form if the employee contributes to the premium.
Attach copies of employee’s medical information relating to the disability (if available).
Attach a copy of the employee’s formal job description or a detailed description of primary
duties.
Attach a copy of all payroll documentation and attendance records for the last six months.
If Waiver of Premium claim, attach the Basic and/or Optional enrollment form, payroll record
and other required documentation.
NOTE:
FOR TRANSITION CLAIMS:
If claimant is transitioning from a Sun Life Assurance Company of
Canada Short Term Disability claim to
a Long Term Disability claim, only fill in the shaded boxes on
page 4
. Then complete the rest of the Employer portion of this claim packet.
FOR NON-TRANSITION CLAIMS: Fill out the entire Employer portion of this packet.
Mail or fax the completed claim form to:
Sun Life Assurance Company of Canada
Group Long Term Disability Claims
P.O. Box 81830
Wellesley H
ills, MA 02481
Fax:
(781) 304-5537
Failure to provide complete and accurate information could result in the need for additional
claims investigation which could delay the initial benefit payment.
919310
XGR/1640 LTD Claim Packet - Employer Page 2 of 7
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long Term Disability Claim Packet - Employer
Fraud Warnings
State law requires that we notify you of the following:
General f
raud warning: 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.
AK
: 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.
AL:
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.
AR, LA, MA,
MN, RI, TX, 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.
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 a loss is subject to
criminal and civil penalties.
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
insura
nce 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 set
tlement or
award payable from insurance proceeds shall be reported to the Colorado Division of Insurance
within the Department of Regulatory Agencies.
DC
: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or kno
wingly presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
DE, ID, and IN
: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, files a state
ment of claim containing any false, incomplete or misleading information is
guilty of a felony.
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, incomp
lete or misleading information
is guilty of a felony of the third degree.
KS
: 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 may be guilty of insurance fraud as determined by a court of law.
919310
XGR/1640 LTD Claim Packet - Employer Page 3 of 7
Claimant:
DOB:
Policy no.:
CC no:
Fraud Warnings continued
KY
: Any person who knowingly and with 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.
MD:
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 fine
s and confinement in prison.
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 include
imprisonment, fines and denial of insurance benefits.
NH
: 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 for insurance fraud, as provided in RSA 63
8:20.
NJ
: Any person who knowingly files a statement of claim containing any false or misleading
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 k
nowingly presents false information in an application for insurance is guilty of a crime
and may be subject to
civil fines and criminal penalties.
OH
: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, su
bmits an application or files a claim containing a false or deceptive statement is guilty
of insurance fraud.
OK
: 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.
OR and VA
: 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 may have violated state law.
PR
: 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
by a fine of not less than five thousand dollars ($5,000) and not more t
han 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 circumstan
ces are present, it may be reduced to a
minimum of two (2) years.
TN 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, f
ines and denial of insurance benefits.
VT
: Any person who knowingly presents a false statement in an application for insurance may
be guilty of a criminal offense and subject to penalties under state law.
919310
XGR/1640 LTD Claim Packet - Employer Page 4 of 7
Claimant:
DOB:
Policy no.:
CC no:
Sun Life Assurance Company of Canada
Long Term Disability Claim Packet - Employer
Employer’s Statement
1 General Information
If claimant is transitioning from a Sun Life Assurance Company of Canada Short Term
Please print clearly. Disability claim to a Long Term Disability claim, only fill in the shaded boxes.
Return to:
Sun Life Assurance
Company of Canada
Group LTD Claims,
SC
4328
1 Sun Life Exec. Park
P.O. Box 81830
Wellesley Hills, MA 02481
Fax:
(781) 304-5537
Name of employer
Group policy number
Class
Street address
City
State
Zip
Name and address of division where employee works (if different from above)
Does your company have a formal Return to Work Program? ......................................... Yes No
Contact Person
Telephone number
2 Employee Information
If claimant is transitioning
from a Sun Life Assurance
Company of
Canada Short
Term Disability claim to
a
Long Term Disability claim,
only fill in
the shaded
boxes
.
Name of employee (first, middle initial, last)
M
F
Social Security number
Date of birth
(m/d/y)
Telephone number
Employee’s street address
City
State
Zip Code
3 Employment and Claim Information
If claimant is transitioning
from a Sun Life Assurance
Company of Canada Short
Term Disability claim to a
Long Term Disability
claim, only fill in the
shaded boxes.
Date hired (m/d/y)
Effective date of coverage
Date last worked (m/d/y)
Hours worked last day
What was the employee’s permanent occupation on his/her last date of work?
How long had employee been in occupation?
Years: Months:
Regularly scheduled work week:
Days per week: Hours per day:
Has the employee’s employment been terminated?
Yes No
If yes, provide termination date
Why did employee cease working?
Is the condition due to an injury or sickness arising out of employee’s job?
Yes No Disputed
Has a Workers’ Compensation claim been filed? ................................................ Yes No
If “yes,” please include the initial report of illness/injury and award/denial notice with this claim.
Name and address of your Workers’ Compensation carrier:
Telephone number
Was employee covered under prior
LTD policy?............... Yes No
Effective date under prior
policy (m/d/y)
Termination date under prior
policy (m/d/y)
Has employee returned to work?
Yes No If yes: With restrictions Full capacity
Date returned (m/d/y)
919310
919310
XGR/1640 LTD Claim Packet - Employer Page 5 of 7
Claimant:
DOB:
Policy no.:
CC no:
Continued on next page
4 Salary and Benefits Information – Complete this section for all claimants.
Please note that
additional financial
information may be
required depending on
your specific policy.
Enrollment form is
required if coverage
is contributory.
Please provide 6 months of payroll records prior to date last worked. Be sure to include documentation of
hours worked,
payments, contributions to LTD, and attendance records.
How was the employee paid?
(check one)
Provide information about other income:
Hourly
$ per hour:
Salaried
$ per week:
Commissions
$
Bonuses
$
Overtime
$
Does
employee contribute toward the LTD premium? ............................... Yes No
If “yes,” attach a copy of employee’s enrollment form
to this claim and indicate percentage contribution...................................
Employee:
%
Employer:
%
Are employee contributions made with pre-tax dollars? ......................... Yes No
5 Other Income Information –
Complete this section for all claimants.
Check all that apply
and provide details for
each source
of income.
Is employee currently receiving, or entitled to receive, benefits from any of the following sources?
Source of income
Amount of each
payment
Weekly or
monthly?
Period/date(s)
covered by
payment
Sick Pay
$
Wkly Mthly
Salary Continuance
$
Wkly Mthly
State Disability
$
Wkly Mthly
Workers’ Compensation
$
Wkly Mthly
Unemployment Compensation
$
Wkly Mthly
Social Security Disability/Retirement
$
Wkly Mthly
Disability/Retirement Pension
$
Wkly Mthly
Automobile No-fault Insurance
$
Wkly Mthly
Union Disability
$
Wkly Mthly
Severance
$
Wkly Mthly
Other:
$
Wkly Mthly
6 Employee’s Occupation Information – Complete this section for all claimants.
Required: Please
submit a copy of the
employee’s formal
job description.
Job title / Major job duties (attach employee’s formal job description)
7 Physical Aspects of Occupation – Complete this section for all claimants.
Please note that
additional occupational
information may
be required.
In a typical work day, give the number of hours the employee spends in each of these positions and if
employee may alternate positions.
May Alternate Positions
Position Total Number of Hours At Will 15-30 Mins. Hourly Never
Sitting
Standing
Walking
Driving
919310
XGR/1640 LTD Claim Packet - Employer Page 6 of 7
Claimant:
DOB:
Policy no.:
CC no:
7 Physical Aspects of Occupation continued –
Complete this section for all claimants.
In a typical work day, the employee must:
Occasionally Frequently Continuously
(1/4 – 2 ½ hours) (2 ½ - 5 ½ hours) (5 ½ - 8 hours) Never
Bend/Stoop
Climb
Reach above shoulder level
Kneel
Balance
Push/Pull
Crawl/Crouch
Lift
lbs.
Carry lbs.
Check all that apply.
Does the employee use feet for repetitive movements, as in operating foot controls?
Right foot Yes
No Left foot Yes
No Both feet Yes
No
What are the major tasks requiring use of one or both hands?
Which of the following describes the employee’s working environment?
Working at heights Exposure to dust, fumes and gases
Operating heavy machinery Changes in temperature or humidity
Precise manual dexterity Other hazards (specify):
8 Non-Physical Aspects of Occupation –
Complete this section for all claimants.
Does employee have to answer customer complaints? ........................................................... Yes No
Is employee primarily evaluated on production? ............................................................... Yes No
Is employee routinely subject to close supervision? .......................................................... Yes No
Does employee work closely with his/her co-workers? ..................................................... Yes No
Is employee responsible for the overall performance of his/her particular
department? .......................................................................................................................
Yes No
Number of people this employee supervises
9 Checklist of Required Attachments – Complete this section for all claimants.
Failure to provide
the following
information could
result in a delay
of the initial
benefit payment.
Attach a copy of the LTD enrollment form if the employee contributes to the premium.
Attach copies of employee’s medical information relating to the disability (if available).
Attach a copy of the employee’s formal job description or a detailed description of primary duties.
Attach a copy of all payroll documentation and attendance records for the last six months.
If Waiver of Premium claim, attach the Basic and/or Optional enrollment form, payroll record and
other required documentation.
10 Certification and Signature – Complete this section for all claimants.
Tip:
To certify eligibility,
mail or fax the employee’s
enrollment form with the
claim.
I certify that the above statements are true and complete. I have read or had read to me the
fraud warning for my state.
Name of person completing this form
Telephone number:
Fax Number:
Title
E-mail address:
Company’s Website:
Signature
X
Date signed
For more information about
Long Term Disability, the claim process and the status of your employees’
claims, log onto your plan administrator web portal.
919310
Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2018 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved.
Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada.
XGR/1640 LTD Claim Packet - Employer Page 7 of 7 1/18
Claimant:
DOB:
Policy no.:
CC no:
919310
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Completed 1 October 2020

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