Form Gc-1502-9 - Employee Request For Information - 2011
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1
2EMPLOYEE REQUEST FOR INFORMATION
Mail this completed form to:
Aetna Life Insurance Company
PO Box 14560
Lexington, KY 40512-4560
Short Term Disability
Phone: 866-326-1380
Long Term Disability
Fax: 866-667-1987
This notice should be completed by Employer and Employee, using BLUE or BLACK ink, and faxed/mailed to Aetna Life Insurance
Company in order to initiate a disability claim. Neither the furnishing of this form, nor its acceptance by the company, shall be
construed as an admission of liability or a waiver of any of the provisions of the plan document.
EMPLOYER INFORMATION
(To be completed by the Employer.)
Employer’s Name
EIN Number
Employer’s Address: Street
City
State
Zip
Work Location (if different from the above)
Supervisor’s name and telephone number
Does member have both Aetna
Aetna Disability Control
Disability
Disability Account
STD
LTD
Disability Plan
Disability and Health Insurance?
Number
Suffix
Yes
No
Complete all applicable
Aetna Health Plan Control Number
Health Plan Suffix Health Plan Account
Health Plan Summary Code
information.
Employee’s Name (Last, First, Middle Initial)
Employee Gender
Employee’s Social Security Number
Male
Female
Date of Hire
STD Coverage Effective
LTD Coverage Effective
Date Last Worked
Was more than a half day completed?
(MM/DD/YYYY)
Date (MM/DD/YYYY)
Date (MM/DD/YYYY)
(MM/DD/YYYY)
Yes
No
Employee’s Occupation
Occupation is:
Date Salary continuation was
Reason employee ceased work
Sedentary
Light
paid through (MM/DD/YYYY)
Moderate
Heavy
Employee’s earnings are:
Number of hours per week
$
Annually
Monthly
Weekly
Hourly
U
U
The portion of the cost of coverage that is paid by the employee with post-tax dollars is non-taxable.
STD
%
LTD
%
U
U
U
U
What percentage of the cost of coverage is paid by the employee in this manner?
If premium deductions are to be withheld please list the amounts (weekly)
FSA –
FSA –
Medical
Life
Dental
AD&D
Vision
Health
Dependent
LTD
Other
Amount
$
$
$
$
$
$
$
$
$
Pre-tax $
%
%
%
%
%
%
%
%
%
Post-tax $
%
%
%
%
%
%
%
%
%
The following is applicable only if the employee also has group life insurance with Aetna:
Basic Life Control Number
Control Suffix
Claim Account
Plan
Amount of Basic Insurance in Force on Date Last Worked
$
Supplemental Life Control Number Control Suffix
Claim Account
Plan
Amount of Supplemental Insurance in Force on Date Last Worked
$
Premium Waiver
DBO-AID
Date Insurance Took Effect
Effective Date Insurance Discontinued if
Type of Provision
Not in Force
Lump Sum
Group Universal Life
(check one):
PTD/ Installment
Was Claimant Required to Submit Evidence of Insurability?
Supplemental Insurance Required Information: Enrollment forms and/or
No
Yes, give date submitted
Screen Prints for current year as of date last worked and 2 years prior.
U
Last Contribution Covered Period Ending (complete only if claimant
If Retired, Provide Retirement Date and Copy of Pension Acceptance.
contributed part of premium)
Name and phone number of person providing the above information:
Date (MM/DD YYYY):
(To be completed by the Employee. Misrepresentation section on back page MUST be signed.)
EMPLOYEE INFORMATION
Employee’s Address: Street
City
State
Zip
Telephone number
May we leave messages on your answering machine?
Date of birth (MM/DD/YYYY)
Yes
No
Date first missed work due to disability (MM/DD/YYYY)
Date returned/will return to work (MM/DD/YYYY)
What is the nature of your disability (diagnosis and/or ICD/CPT Code)?
Were you hospitalized due to this condition?
Yes
No
If Yes, what date were you hospitalized on?
Is this condition work related?
Is this condition the result of an accident?
Is this condition the result of a motor vehicle accident?
Yes
No
Yes
No
Yes
No
What is your occupation?
Briefly describe your job duties
What is your doctor’s name?
What is your doctor’s address and phone number?
Briefly describe how your condition
Has your doctor recommended that you stay out of work because you cannot perform your job at this time?
prevents you from working
Yes
No
If Yes, how long do they expect you to remain out of work?
Have you been disabled as a result of this condition before?
Are you receiving any other form of income?
Yes
No
If Yes, when and how long?
Yes
No
If Yes, please describe:
CF DT 21-023 WKAB-ME
Complete back
GC-1502-9 (5-11) B
R-POD
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