Group Short Term Disability Claim - Guardian Life Page 2
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3EMPLOYER SECTION –
PLEASE PRINT AND COMPLETE IN FULL (QUESTIONS 1-24) TO PREVENT DELAY IN PROCESSING
1. EMPLOYER NAME
2. PLAN NUMBER
3. EMPLOYER ADDRESS
CITY
STATE
ZIP
4. IF BRANCH OR AFFILIATE, PLEASE
5. EMPLOYER SOCIAL
PROVIDE NAME OF PARENT COMPANY
SECURITY OR TAX ID
6. EMPLOYEE NAME
8. EMPLOYEE
7. EMPLOYEE SOCIAL
SECURITY NUMBER
______ - ______ - ______
DATE OF BIRTH ______ /______ /______
9. EMPLOYEE JOB TITLE
10. DATE OF EMPLOYMENT
11. DATE EMPLOYEE EFFECTIVE FOR STD
12. EMPLOYEE INSURANCE
______ /______ /______
______ /______ /______
CLASS _________________
13. ACTUAL LAST DAY WORKED
________________ HOURS/WEEK
MON
TUES
WED
THURS
FRI
SAT
SUN
14. NORMAL WORK SCHEDULE:
______ /______ /______
_______ HRS
________________ HOURS/DAY
15. DATE EMPLOYEE TERMINATED
16. REASON FOR LEAVING WORK:
DISABILITY
RESIGNED
TERMINATED
LAYOFF
LEAVE OF ABSENCE
RETIRED
______ /______ /______
17. CAN THE EMPLOYEE’S JOB BE MODIFIED TO ALLOW FOR RETURN TO WORK?
18. DATE EMPLOYEE RETURNED TO WORK
PART TIME
YES
NO
MAYBE, DEPENDING ON RESTRICTIONS
______ /______ /______
FULL TIME
19. SALARY – PLEASE PROVIDE:
HOURLY
WEEKLY
BI-WEEKLY
SEMI-MONTHLY
MONTHLY
YEARLY
EMPLOYEE’S BASE SALARY (DO NOT INCLUDE BONUS , OVERTIME OR COMMISSIONS)
$_____________________ (PLEASE CHECK FREQUENCY ABOVE)
EMPLOYEE’S TOTAL BONUS AND COMMISSIONS OVER LAST 24 MONTHS
$_____________________
FROM ______ /______ /______ TO ______ /______ /______
(IF APPLICABLE)
EFFECTIVE DATE OF EMPLOYEE'S LAST SALARY CHANGE: _________________________
IF EARNINGS DEFINITION BASES SALARY ON PRIOR YEAR W-2, PLEASE ATTACH A COPY OF
THE PRIOR YEAR W-2 (IF EMPLOYED IN PRIOR YEAR) OR PROVIDE YEAR-TO-DATE SALARY: $_____________________ FROM ______ /______ /______ TO ______ /______ /______
20. DOES THE EMPLOYEE CONTRIBUTE TO THE COST OF THEIR SHORT TERM DISABILITY
21. DO YOU HAVE ANY REASON TO BELIEVE THAT FICA WITHHOLDING SHOULD NOT BE
DEDUCTED FROM THE EMPLOYEE’S BENEFIT?
YES
NO
INSURANCE PREMIUM?
YES
NO
IF “YES”, PLEASE EXPLAIN
IF “YES”, PLEASE BE SURE TO COMPLETE THE FOLLOWING ACCURATELY AND FULLY
__________________% PAID BY EMPLOYEE,
PRE TAX
POST TAX
22. A) DID THIS DISABILITY ARISE OUT OF EMPLOYMENT?
YES
NO
IF “YES”, PLEASE EXPLAIN
B) HAS A WORKERS’ COMPENSATION CLAIM BEEN FILED?
YES
NO
23. I CERTIFY THAT I HAVE REVIEWED THE ABOVE INFORMATION AND THAT THE EMPLOYEE NAMED ABOVE HAS BEEN A FULL-TIME ACTIVE EMPLOYEE FOR WHOM PREMIUMS HAVE BEEN PAID.
AUTHORIZED EMPLOYER SIGNATURE ________________________________________________________________________________________ DATE ____________________________________
PRINTED NAME OF AUTHORIZED PERSON _____________________________________________________________________________________ TITLE ____________________________________
TELEPHONE NUMBER ( ________ ) ________-____________ EXT__________
FAX NUMBER ( ________ ) ________-____________
EMAIL ADDRESS _____________________________________
Please fully complete the following details about the physical aspects of the claimant's job as performed in an 8 hour work day.
24. JOB DESCRIPTION –
Please also attach a description of job duties, if available.
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
NEVER
.25 – 2.5 DAILY
2.5 – 5.5 DAILY
5.5 – 8 DAILY
NEVER
.25 – 2.5 DAILY
2.5 – 5.5 DAILY
5.5 – 8 DAILY
HRS
HRS
HRS
HRS
HRS
HRS
SIT
WALK
STAND
DRIVE
LIFT/CARRY
INDICATE AMOUNT/FREQUENCY BELOW
REACH ABOVE
0-10 LBS
BEND/STOOP
10-20 LBS
USE HANDS FOR
INDICATE ACTIVITY/FREQUENCY BELOW
20-50 LBS
PUSHING/PULLING
50-100 LBS
FINE MANIPULATION
OVER 100 LBS
STRESS LEVEL
LOW
MODERATE
HIGH
VERY HIGH
JOB DESCRIPTION COMPLETED BY _____________________________________________________ TITLE _____________________________________________ DATE ___________________________
You may file STD claims online, and check claim status by visiting us at
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