Form Di-1-Pp - Application For Disability Benefits Covered By Act 139 Page 2
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4PART A
CLAIMANT´S REPORT
1. Name (Last name, and/or husband, and first name) (PRINT LETTER)
2. Social Security Number
3. Sex:
M
F
(For contribution use only)
4. Postal address (Include “Zip Code”):
5. Residential address:
Phone__________________
6. Date of birth (month-day-year)
7. Occupation:
8. Before becoming disabled, I worked until:
Date (month-day-year)
9. My employers during the last 18 months were [State the companies´ names and addresses, dates of employment, and if you worked at the same time for
more than one employer (Part B) for each one.]
a)
b)
From___________________________ To____________________________
From___________________________
To___________________________
(month-day-year)
(month-day-year)
(month-day-year)
(month-day-year)
10. During my disability:
I received
I am receiving
I am managing benefits or income of:
GROSS
GROSS
YES
NO
YES
NO
AMOUNT
AMOUNT
c. Social Security for Chauffeurs
a. My employer or union
$
Date (month -day-year)
$
Vacation pay
d. Social Security (Disability)*
Date (month-day-year)
Date (month -day-year)
Sick leave
d. Social Security (Retirement)*
Date (Month-day-year)
Date (Month-day-year)
Maternity leave
e. State Insurance Fund Corporation (CFSE)*
Date (month-day-year)
Date (month -day-year)
Pension o retirement*
f. ACAA´S Insurance
Date (month -day-year)
Date (month -day-year)
Holidays
g. Veterans
Date (month -day-year)
Date (month -day-year)
Voluntary Pay
h. A Private Plan
Date (month -day-year)
Date (month -day-year)
b.
Unemployment Insurance
i. Other (Specify)
Date (month -day-year)
Date (month -day-year)
* In affirmative case, you must send copy of the letter of approval of Social Security or Pension and copy of documents of the CFSE, if it applies
12. My disability is related to… (In affirmative case, it includes
11. I became disabled (Explain how, where and when your disability occurred. Include
copy of the determination or documents.)
number of the complaint of the Police, if it applies).
YES
NO
My Job
SIF Claim No.(CFSE)___________________
An automobile accident
13. When I became disabled, I was:
employee (a)
unemployed (a)
14. During my disability I worked the period:
From_______________________
To_____________________
(month-day-year)
(month-day-year
)
15. I recovered and I am able to work from:
Date (month-day-year)
17. Are you do payments to ASUME? Yes
No
16. I returned to work in:
Date (month-day-year)
18. I am giving this application after three (3) months of the beginning of my disability for the following reasons:
CERTIFICATCION AND AUTHORIZATION
I certify that I am or I was disabled to work and that all the information provided by me in this form is certain. I know that the Law, in its Sections 3 (o)
and 11 (a), imposes serious punishments---as it fines, jail or both pains, to discretion of Court-by offering deception in order to obtain disability
benefits. I authorize my employer and doctor or any other natural or legal people, to provide to the company or self-insured employer Triple-S Vida,
Inc. all the information necessary for the processing of my application.
Date (month-day-year)
Claimant´s Signature (or mark, if unable to sign)
Witness’ address:
Witness´ name (Printed)
Witness´ signature
Phone:
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