Fillable Initial Statement Of Claim Disability Benefit printable pdf download

Short-Term Disability Benefits

Initial Statement of Claim

HOW TO FILE A CLAIM

Please follow the instructions listed below to avoid unnecessary delays in processing your claim. This form must be fully

completed for each disability claim. If the claim form is not fully completed, the processing of the claim may be delayed.

Employer: 1) Complete and sign Part I answering all questions;

2) Attach job description; and

3) Attach proof of earnings as defined by applicable policy (example: payroll records, W-2, K1, 1099, etc.)

Insured:

1) Complete and sign Part II answering all questions; and

2) Complete and sign the AUTHORIZATION FOR USE IN OBTAINING INFORMATION form, and

3) Have your attending physician complete and sign the ATTENDING PHYSICIAN STATEMENT.

Once completed, please fax to (267) 256-3533 or mail to Reliance Standard Life, P.O. Box 7749, Philadelphia, PA 19101-7749

PART I

FOR EMPLOYER TO COMPLETE

Name of Insured (Last, First, Middle Initial)

Date of Birth

Social Security Number

Policy Number

Job Title

Insurance Class

Hire Date

Date Enrollment Card Signed

Effective Date of Insurance

Date Laid Off (If Applicable)

Date Retired (If Applicable)

Weekly Earnings

Date Last Worked

Date Returned to Work

Is Insured receiving sick leave benefits from your company?

Yes

Reason for Stopping Work:

If “Yes,” specify dates when benefits:

Began:

Ended:

Is disability work related?

Yes

Brief Description of Duties

If “Yes,” explain:

Employer Name & Address

Employer's Telephone Number

Ext.

Authorized Signature

Date

Fax Number

Email Address

PART II

FOR INSURED TO COMPLETE

Home Address (Street, City, State, Zip)

Gender:

Dominant Hand:

Right

Male

Left

Female

Is this claim based on an

Did injury occur at work?

Yes

Date you were first unable to work

If "Yes," for whom were you working?

because of this disability:

accident?

Yes

Date of Accident (if any)

Time

How and where did accident happen?

Name and Address of Attending Physician

Date you returned to work

Are you receiving Unemployment Compensation benefits?

Yes

Are you now receiving or eligible to receive

State Disability

Yes

If "Yes" give name and address of insurer, amount

as a result of this disability:

No Fault Disability

Yes

of income, date benefits began and ended.

Social Security

Yes

Other

Yes

Worker's Compensation

Yes

We are required to withhold federal income tax from any benefit payments upon your request. If benefits are taxable by your

state, we will also withhold state income tax upon your request. We must also send a report to your employer at the end of each

calendar year showing your name, social security number, any benefits paid and any taxes withheld. If you would like us to

withhold any taxes, please indicate the dollar amount to be withheld each week:

Federal Tax to be Withheld

($20.00 Minimum per week, whole dollars only)

State Tax to be Withheld

($ 2.00 Minimum per week, whole dollars only)

Any person who knowingly and with intent to injure Reliance Standard Life Insurance Company files a statement of claim or

submits any information in conjunction with a claim containing fraudulent, false, misleading, incomplete or deceptive information

commits a fraudulent insurance act, which is a crime. These actions will result in the denial of the claim, and are subject to

prosecution under state and/or federal law. Reliance Standard Life Insurance Company will pursue any and all appropriate legal

remedies arising from such fraudulent insurance acts.

Insured’s Signature

Date

Telephone Number

E-Mail Address

EF-1029

Initial Statement Of Claim Disability Benefit

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