Fillable Unum Ltd Cliam Form 1185 02 SC.p65 (Bowie State University)

Fill Online, Printable, Fillable, Blank Unum Ltd Cliam Form 1185 02 SC.p65 (Bowie State University) Form

Use Fill to complete blank online BOWIE STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Unum Ltd Cliam Form 1185 02 SC.p65 (Bowie State University)

On average this form takes 103 minutes to complete

The Unum Ltd Cliam Form 1185 02 SC.p65 (Bowie State University) form is 9 pages long and contains:

  • 0 signatures
  • 246 check-boxes
  • 297 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Bowie State University

BROWSE BOWIE STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1198-02
For use with policies issued by the following Unum [“Unum”] subsidiaries:
Unum Life Insurance Company of America Provident Life and Accident Insurance Company
The Paul Revere Life Insurance Company
Please mail or fax this form to:
The Benets Center, P.O. Box 100158, Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637 Fax: 1-877-851-7624
All Other Time Zones Toll-free: 1-800-858-6843 Fax: 1-800-447-2498
This form should be used for the following types of claims only:
• Long Term Disability (LTD)
• Individual Income Protection (IIP)
• Voluntary Workplace Benets (VWB)
• Integrated LTD/IIP/Life Insurance Waiver of Premium and/or VWB
This form must be completed by the Attending Physician, the Employee, and the Employer, and be returned promptly for consideration of benets. All questions on
this form must be answered in full. Incomplete or illegible answers may result in delay of benet consideration. Please return this form as soon as possible after the
rst day you are unable to work. Please keep a copy of this form and any attachments for your records.
Our centralized mail processing center, located in Columbia, SC, services our Benets Centers located in:
• Chattanooga, TN • Glendale, CA • Portland, ME
The employee is responsible for completion of all portions of this form without expense to the Unum subsidiaries.
INSTRUCTIONS:
A. Attending Physician’s Statement: This section must be completed by the physician PRIMARILY responsible for your care. Please make sure all dates of
treatment are indicated in this section and that your physician personally signs and dates this claim form.
B. Claimant’s Statement: This section must be completed by you, the employee. It includes a Physician/Medication page that must also be completed by you.
If necessary, you may include additional information on the back of this page. To avoid delay in evaluating your claim, advise your physician(s) to attach
copies of medical records and test results.
C. Direct Deposit Request: This section must be completed by you, the employee, if you wish to have your Long Term Disability and/or your Individual
Disability benets deposited directly into your bank account.
D. Employment Statement: The employer must complete this form.
Authorization: Sign and date this form. Provide a copy of the signed and dated form to your attending physician.
Please enclose any additional information that you feel will assist us in evaluating this claim.
CLAIM FRAUD WARNING STATEMENTS
For your protection, the laws of several states, including Alaska, Arizona, Arkansas, Delaware, Idaho, Indiana, Kentucky, Louisiana, Minnesota, New Hampshire, Ohio
and Oklahoma, and others require the following statement to appear:
Fraud Warning
Any person who knowingly, and with intent to injure, defraud, or deceive an insurance company, les a statement of claim containing any false, incomplete, or
misleading information is guilty of insurance fraud, which is a felony.
Fraud Warning for California Residents
For your protection, California law requires the following to appear:
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
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, Maine, Tennessee and Virginia Residents
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may
include imprisonment, nes or a denial of insurance benets.
Fraud Warning for Florida Residents
Any person who knowingly and with intent to injure, defraud or deceive any insurance company, les a statement of claim or an application containing false, incomplete
or misleading information is guilty of a felony of the third degree.
Fraud Statement for New Jersey, New Mexico and Pennsylvania Residents
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 Statement for New York Residents
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 Statement for Puerto Rico Residents
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 (5,000) dollars and not more than ten thousand
(10,000) dollars, 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.
CLAIM FOR INCOME PROTECTION BENEFITS
The Benets Center, P.O. Box 100158
Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637 Fax: 1-877-851-7624
All Other Time Zones Toll-free: 1-800-858-6843 Fax: 1-800-447-2498
CLAIM FOR INCOME PROTECTION BENEFITS
The Benets Center, P.O. Box 100158
Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637 Fax: 1-877-851-7624
All Other Time Zones Toll-free: 1-800-858-6843 Fax: 1-800-447-2498
A. ATTENDING PHYSICIAN’S STATEMENT (PLEASE PRINT)
Name of Patient Home Telephone Number Date of Birth Social Security Number
( )
Employer Name/Address Employer Telephone Number
( )
Instructions: The following sections must be completed and signed by the attending physician. The purpose of this report is to assist us in making a disability
determination. If this claim is related to a normal pregnancy, complete the normal pregnancy section. Otherwise, please complete all applicable sections of this
form and provide copies of supporting reports, such as office notes, medical records, consultations and/or testing. In all situations, you must complete
the signature block at the bottom of this form.
NORMAL PREGNANCY
a) Expected Delivery Date: b) Actual Delivery Date: c) Delivery Type: Vaginal C-Section
Date First Unable to Work: Date Hospitalized:
ALL OTHER CONDITIONS
Patient Information
a) Height: Weight: b) Date of rst visit regarding current conditions?
c) Date patient ceased work because of condition? d) Did you advise patient to cease work? Yes No If yes, when?
e) Has the patient been treated for the same/similar condition in the past?
Yes No If yes, when?
If yes, please describe:
f) Is the patient’s condition due to injury or sickness involving the patient’s employment? Yes No Unknown
Diagnosis and Treatment
Primary Diagnosis
a) What is the primary diagnosis preventing your patient from working?
Please include Primary ICD-9 and/or DSM IV Multi-Axial Diagnoses and Codes
b)
Date of last examination:
c) Describe Reported Symptoms:
d)
Describe Physical Findings (MRIs, X-rays, EMG/NCV studies, Lab tests, clinical ndings, GAF etc.):
Other Conditions (Please attach additional information as necessary)
Are there other conditions that prevent your patient from working? If so, please list with information as follows:
a)
Secondary ICD-9s: Diagnosis:
Secondary ICD-9s: Diagnosis:
b) Describe Reported Symptoms:
c)
Describe Physical Findings (MRIs, X-rays, EMG/NCV studies, Lab tests, clinical ndings, GAF etc.):
Treatment
a) Describe the patient’s current treatment program (include facilities name/address if applicable):
b) Medications (Please list all medications including dosage and frequency):
c) Has patient been hospitalized? Yes No Date Hospitalized: through:
d) Was surgery performed? CPT 4 Code(s): Date Surgery Performed:
Name/Address of facility:
e) Is the patient still under your care? Yes No Final Date of Treatment:
1198-02
1198-02
Claimant Name: Social Security Number:
Other Providers: Please supply complete name, contact information and specialty of any other treating physicians or hospitals.
Treatment
Name Specialty Address Phone # Fax # From To
Physical Capabilities
a)
Patient’s ability to: ( Please Check Number of Hours Per Workday and How Often)
Number of Hours
How Often
Sit 0 1 2 3 4 5 6 7 8 Continuously Intermittently
Stand 0 1 2 3 4 5 6 7 8 Continuously Intermittently
Walk 0 1 2 3 4 5 6 7 8 Continuously Intermittently
b) Patient’s ability to: (Please Check)
Never Occasionally Frequently Continuously
0% 1-33% 34-66% 67-100%
Climb    
Twist/bend/stoop    
Reach above shoulder level    
Operate heavy machinery   
c) Patient’s ability to lift/carry: (Please Check)
Never Occasionally Frequently Continuously
0% 1-33% 34-66% 67-100%
Up to 10 lbs.    
11 to 20 lbs.    
21 to 50 lbs.    
51 to 100 lbs.    
Psychological Features
Are there any cognitive decits or psychiatric conditions that interfere with the patient’s ability to perform his/her occupation? If so, please describe specically how
any identied condition prevents the patient from performing his/her occupation.
Return to Work
a) When do you expect improvement in the patient’s capabilities?
b) RESTRICTIONS (activities patient should not do)
c) LIMITATIONS (activities patient cannot do)
FRAUD NOTICE: Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penal-
ties. This includes Employer and Attending Physician portions of the claim form.
Print or Type Name Degree Medical Specialty
Street Address Telephone Number
( )
City State ZIP Code Fax
( )
Signature of Physician Date
SSN or Employer’s ID Number: Are you, the physician, related to this patient? Yes No
If yes, what is the relationship?
d) Patient’s ability to perform: (Please Check)
Never Occasionally Frequently Continuously
0% 1-33% 34-66% 67-100%
R L R L R L R L
Fine Finger movements        
Hand/eye coordinated movements        
Pushing/Pulling        
Dominant Hand  Right Left
B. CLAIMANT’S STATEMENT (PLEASE PRINT)
1. Claimant’s Name (as printed on your Social Security Card) Home Telephone Number Date of Birth Social Security Number
( )
Cell Telephone Number
( )  Male  Female
Home Address (Street, City, State, ZIP)
The state in which you work: Preferred e-mail address where you can be reached:
2. Employer Name Policy Number
If you have returned to work, list the duties of the # of weekly hours
occupation you are performing. spent at duty
Have you returned to work? If yes, when?
Part Time: Full Time:
Hours per week:
If you have not returned to work, when do you expect to return?
Part Time: Full Time:
What specic job duties are you unable to do as a result of your sickness/injury?
In order to expedite your claim, please provide medical records to support your inability to perform your occupational duties.
3. Marital Status: If you are married, spouse’s name Spouse’s Date of Birth Is spouse employed?
Single Married Widowed Divorced Yes No
List your dependent children who are under age 25 (attach additional sheets if necessary).
Name Date of Birth Attending School?
Yes No
Yes No
4. Is this disability due to Motor Vehicle Accident Other Accident Sickness Work-related Injury/Sickness Pregnancy
Please describe your medical condition(s) or injury that is resulting in your disability. Advise when the symptoms rst appeared. If related to an injury, advise
when, where and how the injury occurred.
5. Date Last Worked Number of Hours Worked on Date Last Worked
6. Check the other income benets you are receiving or are eligible to receive as a result of your disability and complete the information requested.
If you have been approved or denied for any of these benefits, please send a copy of award or denial notification.
Social Security/Retirement Yes No Social Security/Disability Yes No Dependent Social Security Yes No
Canada Pension Plan Yes No State Disability Yes No Third Party Settlement/Income Yes No
Worker’s Compensation Yes No Pension/Retirement Yes No Pension/Disability Yes No
Unemployment Yes No No-Fault Insurance Yes No
Short Term Disability Yes No – Ins. Co. Name and Policy #
Any other insurance coverage Yes No – Ins. Co. Name and Policy #
7. For Fully-Insured Plans – If your request for benets is approved, do you want Federal Income Tax withheld from your check? Yes No
If yes, please indicate dollar amount $ _____________________ (Note: Minimum withholding is $88.00 per month)
Do you want State Income Tax withheld from your check? Yes No
If yes, please indicate dollar amount $ _____________________ (Note: The amount indicated must be a whole dollar increment)
For Self-Insured Plans – Attach a copy of your completed W-4 for accurate calculation of Federal and State income taxes. If not provided, we will withhold 25%
of your benet for Federal Income Tax and the maximum withholding amount for State Income Tax.
If you do not know if you are covered under a fully-insured or self-insured plan, please contact your employer for assistance..
8. If benets are approved, do you want these benets to be automatically deposited into your bank account? Yes No If yes, please complete the Direct
Deposit Request of this form and return it to us along with this completed claim form. Note: This service is not available for self-insured group plans.
9. Are you currently employed by another employer? Yes No If yes, please advise the name and telephone number of that employer.
I have read and understand the fraud notices listed on the instruction page of this form.
The above statements and the information provided on the Physician/Medication list (if applicable) are true and complete to the best of my knowledge and belief.
(Your signature is required for benefit consideration.)
_______________________________________________________ ________________________________________
Signature Date
1198-02
CLAIM FOR INCOME PROTECTION BENEFITS
The Benets Center, P.O. Box 100158
Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637 Fax: 1-877-851-7624
All Other Time Zones Toll-free: 1-800-858-6843 Fax: 1-800-447-2498
B. CLAIMANT’S STATEMENT — Physician/Medication List (PLEASE PRINT)
To avoid delay please answer all questions as completely as possible. Please attach additional pages if needed.
Claimant’s Full Name Policy No.
Please list ALL treatment providers with whom you are currently treating.
( )
1) ____________________________________ ________________________________________________ _______________________________
Provider Name Mailing Address Telephone No.
( )
____________________________________ ________________________________________________ _______________________________
Specialty City State Zip Fax No.
____________________________________ _________________________________
Frequency of Treatment Date of Last Visit
( )
2) ____________________________________ ________________________________________________ _______________________________
Provider Name Mailing Address Telephone No.
( )
____________________________________ ________________________________________________ _______________________________
Specialty City State Zip Fax No.
____________________________________ _________________________________
Frequency of Treatment Date of Last Visit
( )
3) ____________________________________ ________________________________________________ _______________________________
Provider Name Mailing Address Telephone No.
( )
____________________________________ ________________________________________________ _______________________________
Specialty City State Zip Fax No.
____________________________________ _________________________________
Frequency of Treatment Date of Last Visit
Please list any recent hospital confinements.
1) ____________________________________ ________________________________________________ _______________________________
Hospital Address Dates of Connement
____________________________________ ________________________________________________
Procedure City State Zip
2) ____________________________________ ________________________________________________ _______________________________
Hospital Address Dates of Connement
____________________________________ ________________________________________________
Procedure City State Zip
Please list all current medications.
Prescription Name
Dosage Prescribing Physician
1) ________________________________________ _____________________________ _________________________________________
2) ________________________________________ _____________________________ _________________________________________
3) ________________________________________ _____________________________ _________________________________________
4) ________________________________________ _____________________________ _________________________________________
5) ________________________________________ _____________________________ _________________________________________
6) ________________________________________ _____________________________ _________________________________________
7) ________________________________________ _____________________________ _________________________________________
8) ________________________________________ _____________________________ _________________________________________
9) ________________________________________ _____________________________ _________________________________________
1198-02
CLAIM FOR INCOME PROTECTION BENEFITS
The Benets Center, P.O. Box 100158
Columbia, SC 29202-3158
Pacic
Time Zone Toll-free: 1-877-851-7637 Fax: 1-877-851-7624
All Other Time Zones Toll-free: 1-800-858-6843 Fax: 1-800-447-2498
C. DIRECT DEPOSIT REQUEST
If your claim is approved, we are pleased to offer you the security and convenience of having your monthly benet check
deposited electronically to your bank account. Direct Deposit means no more mail delays or trips to the bank to cash your check.
● How does direct deposit work?
Each month, our bank will transfer your benet payment directly into your bank account. We recommend this payment
option because it is predictable, safe and convenient. This is the same system enjoyed by over 15 million Social Security
recipients.
● How do I sign up?
Complete the below section of this form and forward to us. Be sure to print the information clearly. You may want to verify
your account and transit/routing numbers with your bank to avoid delays.
● How soon can my direct deposits begin?
To ensure accuracy, your Direct Deposit will begin within 30 days of our notication to your bank. This means you may
still receive checks by mail after you send in your request. Once Direct Deposit processing begins, your funds will be
deposited into your bank account on the second business day after the day your benet payment is processed.
● What if I have questions?
Call our Customer Service Line at 1-800-413-7671. This toll-free number is available Monday through Friday from 8:00
A.M. to 4:00 P.M. EST.
● What happens if I am out of town when the benefit payment is due?
Your deposit is in your account. You may access it anytime after it is deposited.
● What if I change banks?
Simply call and we will send a request form for your completion or you can provide us with the new bank information in
writing. You may receive a paper check in the mail for one payment while we process your change request.
● Can I change my mind?
Yes. You can start or stop Direct Deposit at any time. Just write and tell us.
● Now what?
We will transfer your benets directly to your bank every month. No more waiting for the mailman, standing in line at the
bank, or remembering to send us a change of address each time you establish a temporary residence.
1198-02
CLAIM FOR INCOME PROTECTION BENEFITS
The Benets Center, P.O. Box 100158
Columbia, SC 29202-3158
Pacic
Time Zone Toll-free: 1-877-851-7637 Fax: 1-877-851-7624
All Other Time Zones Toll-free: 1-800-858-6843 Fax: 1-800-447-2498
Social Security Number:
Name:
Address:
Phone: ( ) ____________________________________
I authorize Unum to deposit my Benet payments to the bank
shown here.
Signature: _____________________ Date: _______________
Name of Bank _____________________________________
City State Zip
Phone ( )
Type of Account Checking Savings
Account Number
Transit/Routing Number*

*Checking (Attach a Voided Check)
*Savings (Contact Bank/Credit Union for Transit/Routing Number)
1198-02
D. EMPLOYMENT STATEMENT (PLEASE PRINT)
Type of Coverage (CHECK ALL THAT APPLY)
Long Term Disability Individual Disability Waiver of Premium (Life Insurance) Voluntary Workplace Benefits
1. Employer Name Employer’s Phone Number
( )
Employer Address (Street, City, State, ZIP)
Policy Numbers Division Number / Class Number Division Description / Class Description
2. Claimant’s Name Claimant Phone Number
( )
Claimant’s Address (Street, City, State, ZIP)
Social Security Number Date of Hire Effective Date of LTD Insurance Effective Date of ID Insurance Date Last Worked
Claimant’s Work Status: Full-time Part-time Exempt Non-exempt Bargaining Non-bargaining
Did the claimant’s job duties and/or hours change prior to his/her last day worked due to disability? Yes No If yes, please explain.
Has the claimant’s employment been terminated? Yes No If yes, please provide termination date:
3. Has claimant returned to work? Yes No If yes, date: Full Time Part Time Hours Per Week
4. Job Title/Major Job Duties (Please attach a copy of claimant’s job description)
5. How was the LTD premium paid for the plan year in which the disability occurred?
Percentage paid by Employer ________ Was the premium amount paid by the employer included in the employee’s W-2? Yes No
Percentage paid by Employee ________ Pre-tax Post-tax
6. How was the ID premium paid for the plan year in which the disability occurred?
Percentage paid by Employer ________ Was the premium amount paid by the employer included in the employee’s W-2? Yes No
Percentage paid by Employee ________ Pre-tax Post-tax
7. Year to Date Earnings (for FICA % Deductions) $
8. How was the claimaint paid? (please check all that apply)
Hourly Salary Overtime Bonus Commissions Other
What is the earnings gure you use to compute premium payments for this claimant on an annual basis? $
Salary/Wage prior to date last worked (refer to Earnings definition in your contract).
Hourly Weekly Bi-Weekly Semi-Monthly Bonuses (per week) Commissions (per week)
$ $ $
9. Financial Documentation (please refer to your contract for your Earnings denition and attach the appropriate documentation).
Salary Only/Current Earnings denition: Attach copy of payroll records or paystubs for 3 months just prior to disability.
Bonus/Commissions Included: Attach copy of payroll records for the 12 or 24 months (see definition) just prior to disability.
Other Earnings denitions: Attach referenced document per Earnings definition (W-2, K-1s, Schedule Cs, teacher’s contract, etc.).
CLAIM FOR INCOME PROTECTION BENEFITS
The Benets Center, P.O. Box 100158
Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637 Fax: 1-877-851-7624
All Other Time Zones Toll-free: 1-800-858-6843 Fax: 1-800-447-2498
1198-02
( )
( )
Claimant Name: Social Security Number:
10. Claimant Pre-Tax Withholdings: Indicate pre-tax withholdings in effect just prior to disability
401(k)/403(b) %; Pre-tax medical and other insurance $ /week; Flexible spending account $ /week
11. Date of last Salary/Wage Increase Work Schedule at time last worked: Days/Week Hours/Day Hours/Week
Check off regular work days: Sun Mon Tues Wed Thurs Fri Sat Number of hours on date last worked:
Date paid through: For: Salary Continuation Vacation Pay Accrued Sick pay Other
Paid Time Off/Sick Leave balance as of last day worked:
12. Does the claimant have an ownership interest in this business? Yes No If yes, what is the % of ownership? %
Type of business entity? Regular Corporation S Corporation Partnership Sole Proprietorship
13. If this is a Flexible Benets Plan, indicate which option of coverage this claimant has chosen.
Previous Plan Year - Date of Open Enrollment ____________Option ________ Current Plan Year - Date of Open Enrollment ____________Option ________
15. Prior LTD Carrier Name Effective Date
Address (Street, City, State, ZIP) Termination Date
If yes, weekly or
15. Is claimant eligible for: Yes No monthly amount Weekly Monthly When do benets begin? When do benets end?
Salary Continuation $ 
State Disability $ 
Other Disability Benets $
Social Security $
Worker’s Compensation $
Is the claim the result of a work related injury or sickness? Yes No
If so has Workers’ Compensation
claim been led? If yes, Name and Address of Carrier
Health Insurance If yes, Name and Address of Carrier
Life Insurance If yes, please provide the amount of coverage: $
If Workers’ Compensation claim has been denied, please submit a copy of denial with this claim.
16. Information about your pension plan (Please send copy of Plan Summary) (Do not complete for maternity claim)
Do you have a pension plan? If yes, what type?
Yes No Dened benet Dened contribution 401(k)/403(b) Prot Sharing Other: (specify)
Is claimant eligible for your pension plan? If eligible, does the claimant participate? What % does claimant contribute?
Yes No Yes No
If the claimant is participating, when is he or she eligible for benets under the plan?
17. If the claimant is released to return to work with restrictions and limitations, are you willing to accommodate?
The above statements are true and complete to the best of my knowledge and belief.
Name of Person Completing Form Telephone Number
Title of Person Completing Form E-mail Address Fax Number
Signature Date Signed
Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
1198-02-AUTH
NOTE: This authorization is designed to comply with the Health Insurance Portability and
Accountability Act (HIPAA) Privacy Rule. You are not required to sign the authorization, but if you
do not, Unum may not be able to evaluate or administer your claim(s). Please sign and return this
authorization to The Benets Center noted above.
Authorization
I authorize any health care provider including, but not limited to, any health care professional,
hospital, clinic, laboratory, pharmacy or other medically related facility or service; health plan;
rehabilitation professional; vocational evaluator; insurance company; reinsurer; insurance service
provider; third party administrator; producer; the Medical Information Bureau; GENEX Services,
Inc.; the Association of Life Insurance Companies, which operates the Health Claims Index and
the Disability Income Record System; government organization; and employer that has information
about my health, nancial or credit history, earnings, employment history, or other insurance claims
and benets including Social Security benets, to disclose any and all of this information to persons
who administer claims for Unum, its insurance subsidiaries* and duly authorized representatives
(“Unum”). Information about my health may relate 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 understand that any information Unum obtains pursuant to this authorization will be used to
evaluate and administer my claim(s) for benets, including any assistance in my return to work.
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.
This authorization is valid for two (2) years from the date below, or the duration of my claim,
whichever is shorter. A photographic or electronic copy of this authorization is as valid as the
original. I understand I am entitled to receive a copy of this authorization.
I may revoke this authorization in writing at any time except to the extent Unum has relied on the
authorization prior to notice of revocation or has a legal right to contest a claim under the policy
or the policy itself. I understand if I revoke this authorization, Unum may not be able to evaluate
or administer my claim(s) and this may be the basis for denying my claim(s). I may revoke this
authorization by sending written notice to the address above.
I understand if I do not sign this authorization or if I alter its content in any way, Unum may not be
able to evaluate or administer my claim(s) and this may be the basis for denying my claim(s).
_____________________________________
_ ________________________________
(Claimant Signature) (Date Signed)
______________________________________ ________________________________
(Print Name) (Social Security Number)
I signed on behalf of the claimant as __________________(indicate relationship). If Power of
Attorney Designee, Guardian, or Conservator, please attach a copy of the document granting
authority.
* This authorization is valid for the following Unum insurance subsidiaries: Unum Life Insurance
Company of America, Provident Life and Accident Insurance Company, The Paul Revere Life
Insurance Company.
FOR EMPLOYEE TO COMPLETE
CLAIM FOR INCOME PROTECTION BENEFITS
The Benets Center, P.O. Box 100158
Columbia, SC 29202-3158
Pacic Time Zone Toll-free: 1-877-851-7637 Fax: 1-877-851-7624
All Other Time Zones Toll-free: 1-800-858-6843 Fax: 1-800-447-2498
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Unum Ltd Cliam Form 1185 02 SC.p65 (Bowie State University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document