Form M20392 - Employers Statement For Disability Benefits Page 2
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12. Has claimant returned to work: Full Time:
Yes
No
If Yes, on what date? ______/______/______
Month
Day
Year
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Part Time/Light Duty:
Yes
No
If Yes, on what date? ______/______/______
Month
Day
Year
(Please provide details of part time or light duties in REMARKS.)
If No, when do you expect claimant to resume work? ______/______/______
Month
Day
Year
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A. Is claimant receiving or entitled to any weekly or monthly disability benefits?
Yes
No
If Yes, give amounts and how long claimant is eligible: ______________________________________
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B. Is claimant receiving or entitled to any pension or retirement benefits?
Yes
No
If Yes, give amounts: __________________________
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C. Is claimant receiving or entitled to any Worker’s Compensation/Employer Liability Benefits?
Yes
No
If Yes, give amounts: __________________________
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D. Do you pay any portion of the claimant’s Mutual of Omaha coverage premium?
Yes
No
If Yes, what percent? ________________
E. Please provide a description of the claimant’s job duties _____________________________________
___________________________________________________________________________________
___________________________________________________________________________________
F. REMARKS: ________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Employer’s Information:
_______________________________________________
_______________________________________
Employer’s Signature
Company Name
_______________________________________________________________________ _____-_____-_____
Mailing Address
City
State
ZIP Code
Telephone Number
Individual to contact if necessary (please print):
_______________________________________________________________________ _____-_____-_____
Name
Title
Telephone Number
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Parent category: Business