Group Short Term Disability Claim - Guardian Life
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1
2
3Group Short Term Disability Claim
To expedite your claim review, STD claims may be filed on-line by visiting us at
.
Or, you may complete the form and submit by fax to (610) 807-8270 or email to
You may also send to: Group STD Claims, P.O. Box 14331, Lexington, KY 40512
Customer Service toll-free: 1-800-268-2525
EMPLOYEE SECTION
- PLEASE PRINT AND COMPLETE IN FULL TO PREVENT DELAY IN PROCESSING
1. EMPLOYEE NAME
2. PLAN NUMBER
3. EMPLOYER NAME
4. EMPLOYEE HOME MAILING ADDRESS
CITY
STATE
ZIP
5. EMPLOYEE TELEPHONE NUMBER
( ________ ) ________-____________
EMPLOYEE EMAIL ADDRESS
6. DATE OF BIRTH
7. SOCIAL SECURITY NUMBER
10. NUMBER OF
8.
MALE
9.
SINGLE
MARRIED
WIDOWED
DEPENDENTS
FEMALE
LEGALLY SEPARATED
DIVORCED
UNDER AGE 18 ________________
______ /______ /______
______ - ______ - ______
11. IS DISABILITY DUE TO YOUR EMPLOYMENT?
YES
NO
12. IS DISABILITY DUE TO AN ACCIDENT?
YES
NO
IF “YES”, HAVE YOU FILED A WORKERS’ COMPENSATION CLAIM?
YES
NO
IF “YES”, DO YOU INTEND TO FILE SUIT?
YES
NO
13. IF YOU ANSWERED “YES” TO QUESTION (11) AND/OR (12), PLEASE PROVIDE THE FOLLOWING
14. DATE SYMPTOMS FIRST APPEARED
15. RETURN TO WORK DATE
ACTUAL
DATE OF ACCIDENT
TIME
PLACE
______ /______ /______
POSSIBLE
______ /______ /______
ACCIDENT DETAILS
16. ARE YOU ELIGIBLE TO RECEIVE ANY OTHER INCOME (SOCIAL SECURITY, WORKERS’ COMPENSATION, STATE DISABILITY, PENSION, NO-FAULT, ASSOCIATION/INDIVIDUAL DISABILITY
PLANS AND SALARY CONTINUATION AND/OR SICK LEAVE BENEFITS, ETC.)?
YES
NO
IF “YES”, ATTACH A COPY OF THE AWARD LETTER OR SUPPLY TYPE OF BENEFITS,
AMOUNT, FREQUENCY, TELEPHONE NUMBER, AND IDENTIFICATION NUMBER OF SOURCE (ATTACH A SEPARATE PAPER IF NEEDED)
17. IF YOUR REQUEST FOR SHORT TERM DISABILITY IS APPROVED AND YOUR BENEFIT IS TAXABLE, PLEASE GIVE AMOUNT YOU WANT US TO WITHHOLD PER
WEEK FOR FEDERAL INCOME TAX (MUST BE WHOLE DOLLAR AMOUNT OF AT LEAST $20 PER WEEK AND MAY NOT REDUCE BENEFIT TO LESS THAN $10). $_________ OR _________%
18. I AUTHORIZE ANY PHYSICIAN, MEDICAL PRACTITIONER, HOSPITAL, CLINIC, OTHER HEALTH FACILITY, CONSUMER REPORTING AGENCY, THE MEDICAL INFORMATION BUREAU, SOCIAL
SECURITY ADMINISTRATION, INSURANCE OR REINSURANCE COMPANY, OR EMPLOYER TO RELEASE ANY AND ALL MEDICAL AND NON-MEDICAL INFORMATION ABOUT ME IN ITS
POSSESSION TO THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA OR ITS LEGAL REPRESENTATIVES. MEDICAL INFORMATION MEANS ALL INFORMATION IN THE POSSESSION OF
OR DERIVED FROM PROVIDERS OF HEALTH CARE REGARDING MY MEDICAL HISTORY, MENTAL OR PHYSICAL CONDITION, OR TREATMENT. I UNDERSTAND THAT THE GUARDIAN WILL
USE THE INFORMATION OBTAINED BY THIS AUTHORIZATION TO DETERMINE ELIGIBILITY FOR INSURANCE OR ELIGIBILITY FOR BENEFITS UNDER AN EXISTING PLAN. THE GUARDIAN WILL
NOT RELEASE ANY INFORMATION OBTAINED TO ANY PERSON OR ORGANIZATION EXCEPT TO REINSURANCE COMPANIES, THE MEDICAL INFORMATION BUREAU, OR OTHER PERSONS
OR ORGANIZATIONS PERFORMING BUSINESS OR LEGAL SERVICES IN CONNECTION WITH MY APPLICATION, CLAIM, OR AS MAY BE LAWFULLY REQUIRED OR PERMITTED, OR AS I MAY
FURTHER AUTHORIZE. I KNOW THAT I MAY REQUEST AND RECEIVE A COPY OF THIS AUTHORIZATION. I AGREE THAT A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE AS VALID AS THE
ORIGINAL. I HAVE THE RIGHT TO CANCEL THIS AUTHORIZATION IN WRITING AT ANY TIME. I AGREE THAT THIS AUTHORIZATION SHALL BE VALID UP TO 24 MONTHS (12 MONTHS IN
KANSAS) FROM THE DATE SHOWN BELOW.
“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. In New York, the person shall
also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.”
"Please Note: Your Social Security number is required for IRS tax reporting purposes. Your Social Security number will not be used or disclosed to anyone for any other purpose and will not be retained in
any record other than that pertaining to the claim."
SIGNATURE OF EMPLOYEE ______________________________________________________________________________________________________________ DATE _______________________
PHYSICIAN SECTION
– PLEASE COMPLETE IN FULL AND RETURN TO PREVENT DELAY IN PROCESSING
1. DIAGNOSIS(ES)
2. ICD-9 CODE(S)
3. HEIGHT
WEIGHT
__________
________ LBS
4. IS PATIENT’S DISABILITY DUE TO
A) EMPLOYMENT
YES
NO
B) ACCIDENT
YES
NO
C) PREGNANCY
YES
NO
5. IF DISABILITY IS DUE TO PREGNANCY, PLEASE INDICATE DATE OF DELIVERY
ACTUAL ______ /______ /______
OR
ESTIMATED ______ /______ /______
(IF UNDELIVERED)
PLEASE INDICATE LMP DATE ______ /______ /______
PLEASE INDICATE TYPE OF DELIVERY
VAGINAL
C-SECTION
MULTIPLE BIRTHS
6. DATE SYMPTOMS FIRST APPEARED
7. DATE OF FIRST VISIT FOR THIS CONDITION
8. DATES OF TREATMENT FOR THIS CONDITION
_______/_______/_______
______ /______ /________
9. DATE PATIENT WAS TOTALLY DISABLED (UNABLE TO WORK)
10. DATES PATIENT WAS HOSPITALIZED (IF APPLICABLE)
FROM ______ /______ /______
THROUGH ______ /______ /______
FROM ______ /______ /______
THROUGH ______ /______ /______
11. IF PATIENT STILL DISABLED, GIVE DATE FOR
12. SURGICAL PROCEDURE(S) DATE(S)/TYPE(S)
CPT ________________________
ANTICIPATED RELEASE TO RETURN TO WORK ______ /______ /______
13. A) IS THE PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION?
YES
NO
14. A) WAS PATIENT REFERRED TO YOU BY ANOTHER PHYSICIAN?
YES
NO
IF “YES”, ARE THERE MEDICALLY NECESSARY ACTIVITY RESTRICTIONS?
YES
NO
IF “YES”, PLEASE GIVE NAME, ADDRESS, AND TELEPHONE NUMBER OF PHYSICIAN
IF “YES”, PLEASE SPECIFY RESTRICTIONS:
14. B) DID YOU REFER PATIENT TO ANOTHER PHYSICIAN?
YES
NO
IF “YES”, PLEASE GIVE NAME, ADDRESS, AND TELEPHONE NUMBER OF PHYSICIAN
13. B) DATE OF PATIENT’S NEXT APPOINTMENT ______ /______ /______
15. DO YOU BELIEVE THE PATIENT IS COMPETENT TO ENDORSE CHECKS AND DIRECT THE
PROCEEDS THEREOF?
YES
NO
16. PRINTED NAME OF PHYSICIAN ________________________________________________________________________________________ SPECIALTY __________________________________
PRINTED ADDRESS OF PHYSICIAN______________________________________________________________________________ TELEPHONE NUMBER ( ________ ) ________-____________
FAX NUMBER ( ________ ) ________-____________ EMAIL ADDRESS ________________________________________________ TAX ID # ___________________________________________
SIGNATURE OF PHYSICIAN _________________________________________________________________________________________ DATE _________________________________________
You may file STD claims online, and check claim status by visiting us at
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