Form M20392 - Employers Statement For Disability Benefits
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2EMPLOYER’S STATEMENT FOR DISABILITY BENEFITS
Claim Number: __________________________
1. Insured’s Name _________________________________________ Date of Birth: ______/______/______
First
Last
Month
Day
Year
2. Date employed: ______/______/______
Month
Day
Year
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3. Claimant is:
Full-time
Part-time # of hours worked per week: ______
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4. Is claimant retired:
Yes
No Retirement date: ______/______/______
Month
Day
Year
5. Claimant’s salary immediately prior to date last worked: Amount $ _________
I I
I I
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(Check one)
Weekly
Monthly
Annually
6. How long was claimant at this salary? ______/______/______ to ______/______/______
Month
Day
Year
Month
Day
Year
7. Date claimant last worked: ______/______/______
Month
Day
Year
8. Initial date of total disability: (Usually one day after date last worked.) ______/______/______
Any difference should be explained in REMARKS.
Month
Day
Year
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9. Is claimant’s job being held open?
Yes
No If No, please explain ___________________________
______________________________________________________________________________________
10. If employment terminated, give date:______/______/______
Month
Day
Year
If necessary, please use REMARKS to explain circumstances.
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11. Could accommodations be made to enable claimant to return to work?
Yes
No
If No, please explain in REMARKS.
MUTUAL OF OMAHA PLAZA
OMAHA, NE 68175
800-775-1000
I
I
M20392 Rev 1-2000
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Parent category: Business